Failure to Withhold Unnecessary Medications as Ordered
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary medications, specifically bowel and antihypotensive drugs. One resident with a diagnosis of hypotension was prescribed midodrine to be administered three times daily, with clear physician orders to hold the medication if the systolic blood pressure (SBP) exceeded a specified threshold. Despite these orders, the medication was administered on at least 24 occasions when the resident's SBP was above the hold parameter, as confirmed by medication administration records and staff interviews. Nursing staff acknowledged that the medication should have been withheld on these occasions but was not. Another resident with a history of bipolar disorder and hip fracture was prescribed senna for constipation, with instructions to hold the medication for loose stools. Review of medication administration and bowel movement records showed that the resident continued to receive senna even after experiencing multiple episodes of loose or watery stools, as indicated by type 6 and type 7 bowel movements. Staff interviews confirmed that the medication should have been withheld until normal stool consistency returned, but this was not done, and the medication was administered daily regardless of bowel movement consistency.