Failure to Follow Physician Orders for Weight Monitoring and Medication Parameters
Penalty
Summary
The facility failed to follow physician orders for two residents regarding daily weight monitoring and administration of blood pressure medication according to specified parameters. For one resident with multiple diagnoses including hypertension, diabetes, chronic kidney disease, and cardiac issues, there was a physician order to obtain daily weights and notify the physician if certain weight gains occurred. However, the medication administration record showed that weights were not recorded for 11 out of 28 days, and staff interviews confirmed the missing documentation and inability to locate the required weights. For another resident with heart failure, COPD, chronic respiratory failure, hypertension, and dementia, there was an order for carvedilol to be held if the systolic blood pressure was below 120 mmHg. Despite this, the medication administration record indicated that the resident received carvedilol on multiple occasions when her systolic blood pressure was below the ordered threshold. Staff interviews confirmed that the medication was administered outside the prescribed parameters, and the facility did not have a specific policy regarding medication administration by parameters, relying instead on state guidelines.