Failure to Ensure Resident Drug Regimen Was Free from Unnecessary Medications
Penalty
Summary
A deficiency was identified in the facility's medication management for one resident who was found to have a physician's order for clonidine, a medication used to treat hypertension, without an active diagnosis of hypertension documented in the medical record. The order specified administration of clonidine as needed for systolic blood pressure (SBP) greater than 160 mmHg, but the resident's medical records from February to May did not show any SBP readings above this threshold, nor was the medication administered during this period. Additionally, the resident was determined to lack capacity to make medical decisions. The same resident was also prescribed sodium chloride 250 mg daily as a supplement, and was administered this medication consistently from February to May. However, laboratory results showed the resident's sodium levels were below the normal range, with the last recorded sodium level at 132 mEq/L on 3/31, and no further sodium monitoring was documented after this date. The Director of Nursing confirmed that no additional sodium level testing had been performed following the abnormal result.