Failure to Follow Professional Standards in Medication Administration and Documentation
Penalty
Summary
The facility failed to follow professional standards of nursing practice for medication administration for multiple residents, as evidenced by incomplete and inaccurate documentation and failure to adhere to medication parameters. On the Garden Unit, review of the Narcotic Book revealed that nine residents did not have their scheduled morning controlled medications documented as dispensed since the previous day, and subsequent review showed that documentation was entered retroactively, not at the time of administration. This indicates that licensed nurses did not document the date and time of controlled medication administration as required by facility policy. For several residents receiving medications with specific parameters, such as antihypertensives, nurses administered medications without obtaining and assessing vital signs immediately prior to administration, instead relying on vital signs from previous shifts. For example, one resident received clonidine despite blood pressure readings below the ordered threshold, and two other residents received lisinopril without current blood pressure or heart rate assessments, with documentation showing use of previous shift vitals. These actions were contrary to provider orders and facility policy, which require assessment of vital signs within the medication pass window to ensure safe administration. Additionally, there were deficiencies in the monitoring and documentation of anticoagulant therapy for a resident with a history of heart disease and DVT. Orders to hold warfarin based on elevated PT/INR results were not followed, resulting in the medication being administered when it should have been held. Documentation of PT/INR results and related orders was incomplete, with missing entries and lack of clarity regarding therapeutic goals. Interviews with nursing staff revealed a lack of understanding of PT/INR protocols and inconsistent documentation practices, further contributing to the deficiency.