Failure to Clarify Medication Orders Leads to Missed Dose
Penalty
Summary
The facility failed to ensure safe and effective pharmaceutical services for a resident with a history of chronic congestive heart failure, hypertension, and dependence on renal dialysis. The resident had a physician's order for furosemide, a diuretic, to be administered twice daily for congestive heart failure. A subsequent order instructed staff to hold all blood pressure medications on the morning of dialysis days. However, the furosemide, which was prescribed for heart failure and not specifically for blood pressure, was withheld by the nurse on a dialysis day without clarifying the order with the physician. During interviews and record reviews, the nurse acknowledged that the furosemide was categorized as a diuretic and not a blood pressure medication, and that the two orders should have been clarified to avoid confusion. The Director of Nursing confirmed that facility policy requires verification of any order that appears inappropriate considering the resident's condition or diagnosis. The failure to clarify the medication orders resulted in the resident not receiving the prescribed furosemide dose as intended.