Failure to Follow Physician Orders and Medication Parameters for Two Residents
Penalty
Summary
The facility failed to follow current physician orders and medication parameters for two residents reviewed for medications. For one resident with moderate cognitive impairment and diagnoses including gastroparesis, malnutrition, and fecal impaction, the most recent signed physician orders specified prochlorperazine as needed for nausea, polyethylene glycol once daily, and metoprolol tartrate with instructions to hold if systolic blood pressure was less than 100. However, the medication administration record (MAR) showed these medications were administered at different dosages and frequencies, and without the specified parameters. Additionally, there was no documentation of blood pressure readings for several months, despite the requirement to monitor before administering metoprolol. Another resident, who was cognitively intact and had diagnoses including neuromyelitis optica and diabetes, had signed physician orders for tacrolimus at specific dosages, hydralazine and carvedilol with instructions to hold if mean arterial pressure (MAP) was less than 65. The MAR reflected administration of tacrolimus at a different dosage and did not include documentation of MAP or pulse prior to administration of hydralazine and carvedilol. Staff interviews revealed confusion regarding the MAP parameter, with some staff indicating they would check heart rate instead, and others acknowledging unfamiliarity with MAP calculations. The facility did not routinely compare the most recent signed physician orders with the MAR, leading to discrepancies in medication administration. The facility's policy required new orders to be entered onto the MAR and verified with the attending physician if unclear, but this process was not consistently followed. The consultant pharmacist failed to identify discrepancies during monthly medication reviews, and the director of nursing confirmed that medication parameters were not always followed and that discrepancies between signed orders and administration were not recognized. The facility did not adhere to its own procedures for reviewing and reconciling physician orders, resulting in residents receiving medications in a manner inconsistent with current orders and parameters.