Failure to Administer and Manage Medications According to Orders and Resident Needs
Penalty
Summary
Three residents experienced deficiencies in the administration and management of their prescribed treatments and medications. One resident with a history of hypertensive emergency, end-stage renal disease, and other significant comorbidities did not receive multiple prescribed medications, including anti-hypertensives, stool softeners, and phosphate binders, on numerous occasions. The medication administration records showed repeated omissions of these medications, with staff documenting the reason as "Other/See Progress Notes." Interviews with nursing staff revealed that medications were routinely held on dialysis days without a physician's order to do so, and there was no documentation supporting this practice. Blood pressure readings before and after dialysis were consistently elevated, and the Director of Nursing confirmed that medications should have been administered as ordered or the timing adjusted appropriately. Another resident with end-stage renal disease, a history of stroke, and hypertension had multiple episodes of elevated blood pressure that were not addressed according to facility policy. The care plan required monitoring and reporting of malignant hypertension and medication side effects, but the medical record showed no documentation that the physician was notified when the resident's blood pressure exceeded the facility's threshold for notification. The resident reported not receiving blood pressure medication on one occasion and was told by a nurse to request it directly. The nurse admitted to not notifying the physician of repeated refusals, and the DON confirmed that no documentation existed of physician notification during periods of significantly elevated blood pressure. A third resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease and neuromuscular bladder dysfunction, refused oral medications multiple times, including tamsulosin, zinc sulfate, and melatonin. The resident's medical record indicated that staff explained the risks and benefits of the medication, but the resident was not capable of understanding due to cognitive impairment. There was no documentation that the physician or responsible family members were notified of the repeated refusals, despite facility policy requiring notification after two or more consecutive refusals. The resident's responsible party was unaware of the refusals and stated this was not typical behavior for the resident.