Failure to Hold Medications on Dialysis Days Results in Significant Medication Errors
Penalty
Summary
The facility failed to ensure that two residents undergoing hemodialysis were free from significant medication errors by not holding medications as ordered by their physicians on scheduled dialysis days. For one resident with end stage renal disease (ESRD) and diabetes mellitus, the physician's order specified to hold medications on dialysis days. However, the Medication Administration Record (MAR) showed that the resident received multiple medications, including furosemide, on dialysis days. The Assistant Director of Nursing (ADON) and Licensed Vocational Nurse (LVN) confirmed that the order was not followed, and the nurses did not clarify which medications should be held, resulting in all medications being administered contrary to the order. Another resident with ESRD, chronic obstructive pulmonary disease (COPD), and diabetes mellitus also experienced a similar deficiency. The care plan indicated that blood pressure medications should be held on dialysis days as ordered by the physician. Despite this, the resident reported receiving blood pressure medications prior to dialysis appointments, and review of the electronic Medication Administration Record (eMAR) confirmed administration of these medications on multiple dialysis days. The LVN responsible for medication administration admitted to not checking the physician's orders before giving the medications. Interviews with nursing staff and the Director of Nursing (DON) further confirmed that the physician's orders were not followed for both residents. The facility's policy required medications to be administered as prescribed, but this was not adhered to, resulting in significant medication errors for residents with complex medical needs during their dialysis treatment.