Medication Administered Outside Physician Parameters
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including dysphagia, cerebral infarction, and HIV, was administered Carvedilol outside of the physician-ordered parameters. The resident's care plan included monitoring and recording medication side effects, and the medication order specified that Carvedilol should be held if the systolic blood pressure (SBP) was less than 110 or the heart rate (HR) was less than 60. Despite these instructions, the medication administration record showed that Carvedilol was given on three occasions when the resident's SBP or HR was below the specified thresholds. Interviews with facility staff revealed that the ADON was unaware of medications being given outside of parameters, while the DON stated that if vital signs were out of range, the nurse could use their judgment to administer the medication but must notify the physician. The facility's policy required obtaining and recording vital signs as necessary prior to medication administration. The failure to adhere to these parameters resulted in the resident receiving medication inappropriately, as documented by the surveyors.