Failure to Administer Medications per Physician Orders Results in Significant Errors
Penalty
Summary
The facility failed to ensure that medications were administered according to physician orders, resulting in significant medication errors for two residents. For one resident with hypertension, bipolar disorder, and insomnia, the physician's orders specified that Amlodipine Besylate should be held if the systolic blood pressure (SBP) was below 120 mm/Hg or diastolic blood pressure (DBP) below 80 mm/Hg, and Hydralazine should only be given if SBP was over 160 mm/Hg and/or DBP over 120 mm/Hg. During medication administration, the LPN prepared and administered both medications when the resident's BP was 155/74 mm/Hg, which was outside the parameters set by the physician's orders. The DON confirmed that these medications should not have been administered under those circumstances. For another resident with paroxysmal atrial fibrillation, hypertension, and a cardiac pacemaker, the physician ordered Digoxin to be administered once daily. The LPN obtained the resident's pulse using a pulse oximeter for less than 30 seconds, rather than obtaining an apical pulse for a full minute as required before administering Digoxin. The medication was then administered without following the correct procedure. The DON verified that the correct method was not used. Facility policy requires medications to be administered safely, timely, and as prescribed, which was not followed in these instances.