Failure to Reassess Long-Term Medication and Lack of Safe Monitoring Parameters for Diabetic Medications
Penalty
Summary
The facility failed to ensure safe medication use practices for three residents by not reassessing the continued need for long-term medication and by not providing clear monitoring parameters for diabetic medications. One resident had been receiving Protonix, a proton pump inhibitor (PPI), daily for several years to treat GERD, but there was no documented reassessment of the ongoing need for this medication. The resident's care plan and physician progress notes did not address the continued use of Protonix, and the consultant pharmacist did not make recommendations regarding the long-term use despite being aware of FDA warnings about risks associated with prolonged PPI use. The physician stated he was not prompted to review the medication and acknowledged there were no active issues requiring its continuation. Two other residents were receiving multiple medications for diabetes, including insulin, but their medication orders lacked specific parameters for nursing staff to follow in response to abnormal blood sugar readings. Orders included instructions for blood sugar monitoring and the use of a reversal agent for hypoglycemia, but did not specify what constituted high or low blood sugar levels that would require intervention before the resident became unresponsive. The consultant pharmacist did not identify the lack of parameters, and the DON agreed that having such parameters would be a safe practice, especially given the use of other medications that could affect blood sugar levels. During medication administration observations, it was noted that nurses administered insulin without clear guidance on when to hold the medication or notify a physician based on blood sugar results. The facility's policy referenced notifying a physician for abnormal blood sugar results, but the actual orders for these residents did not provide the necessary parameters. Both the physician and nursing staff acknowledged the absence of these safety measures and indicated that parameters would be beneficial for safe medication administration.