Failure to Prevent Significant Medication Errors Related to Coreg Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the administration of Coreg (carvedilol) to two residents despite vital signs that did not meet the parameters set by physician orders. Facility policy required medications to be administered in accordance with prescriber orders, which for these residents included holding Coreg if systolic blood pressure (SBP) was less than 110 mmHg or if heart rate was less than 60 beats per minute. For one resident with diagnoses including end stage renal disease, diabetes, and hypertension, the physician order specified to hold Coreg for SBP less than 110 or heart rate less than 60. However, review of the medication administration records showed that Coreg was administered multiple times when the resident's SBP was below 110, with readings as low as 89. The resident's care plan also indicated that medications should be administered per physician order, but this was not followed on several occasions. Another resident with coronary artery disease, diabetes, and hypertension had a physician order to hold Coreg for heart rates less than 60. Despite this, the medication was administered repeatedly when the resident's heart rate was below 60, with documented rates as low as 48 beats per minute. The care plan for this resident also required medication administration per physician order, but this was not adhered to. The Nursing Home Administrator and DON confirmed these findings during an interview.