Failure to Follow Medication Parameters and Complete Neurological Assessments
Penalty
Summary
The facility failed to follow physician's orders regarding medication administration and did not complete required neurological assessments after a resident fall. For one resident with a history of heart failure, hypertension, and coronary artery disease, staff administered midodrine, a medication for low blood pressure, even when the resident's systolic blood pressure was above the ordered threshold of 90. The medication was given multiple times when the resident's blood pressure readings were above this parameter, contrary to the physician's specific instructions. In another case, a resident with diagnoses including diabetes, anemia, seizure disorder, malnutrition, anxiety, and depression experienced a fall while attempting to use the bathroom independently. Although the resident complained of hip pain and refused hospital transfer, the neurological assessment documentation was incomplete. Multiple required elements such as pupil size, level of consciousness, orientation, pain complaints, and extremity assessments were missing from the neurological check flowsheet at several time points following the fall. Interviews with nursing staff and review of facility policies confirmed that staff were expected to follow medication administration parameters and complete thorough neurological assessments after unwitnessed falls. However, in these instances, staff did not adhere to established protocols or physician orders, resulting in incomplete care and documentation for the affected residents.