Failure to Document and Administer Medications per Physician Orders
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of its residents, as evidenced by discrepancies in the documentation and administration of controlled medications and blood pressure medication. For two residents, doses of controlled medications (tramadol and Norco) were removed from the supply as recorded in the controlled drug logs, but there was no corresponding documentation in the Medication Administration Records (MAR) to show that these medications were administered. The Assistant Director of Nursing (ADON) confirmed that the doses should have been documented in the MAR, and acknowledged the lack of documentation for these administrations. Additionally, for another resident, the facility did not follow physician orders regarding the administration of midodrine, a medication for low blood pressure. The physician's order specified that the medication should be held if the systolic blood pressure (SBP) was greater than 130 mmHg. However, the MAR showed that the medication was administered without documentation of blood pressure readings prior to administration, and on two occasions, the medication was given when the SBP exceeded the hold parameter. The ADON verified that there was no documentation of blood pressure readings prior to administration and that the medication should have been held based on the recorded blood pressure values.