Failure to Follow Physician Orders for Medication Administration and Monitoring
Penalty
Summary
The facility failed to ensure that physician's orders were implemented for two residents. For one resident with diagnoses including hypertension, heart failure, anemia, and kidney disease, a physician ordered blood pressure medication to be administered twice daily and at bedtime, with the stipulation that the medication should not be given if the systolic blood pressure was less than 100 mmHg. However, documentation showed that staff administered the medication 28 out of 29 times without recording any evidence that the resident's blood pressure was assessed prior to administration, as required by the physician's order. Another resident, admitted with hypertension, atrial fibrillation, and dysphagia, had a physician's order for daily weight monitoring. The clinical record lacked documentation that the resident's weight was obtained on several specified days. The Director of Nursing confirmed that there was no documented evidence that the required assessments and monitoring were performed according to the physician's orders for both residents.
Plan Of Correction
Physicians' orders were reviewed for all antihypertensive medications to ensure orders reflect parameters prior to medication administration. Physicians' orders were also reviewed for all weights to ensure that orders are carried out and reported as ordered. All residents with antihypertensive medication and daily weights orders have the potential to be affected by the deficient practice. All other residents were audited to ensure that parameters are documented before medication administration and weights are documented and reported to accurately reflect the doctor's orders. Nursing staff will be re-educated on the policies and procedures of medication administration and documentation to accurately reflect the doctor's orders. An audit will be completed by the DON/Designee on all new admissions once a week for at least 3 residents for 6 weeks to ensure that physician's orders are accurately reflected on the MAR/TARS. All findings will be reported and reviewed by the QAPI committee monthly for 3 months. Date of Compliance: 08/26/2025