Failure to Administer Medications as Ordered by Physician
Penalty
Summary
The facility failed to ensure that medications were administered as ordered by physicians for two residents. For one resident, Metoprolol Tartrate was held multiple times by nursing staff due to perceived low blood pressure and pulse, despite the physician's order not including parameters for withholding the medication. The nurses did not notify the provider about their concerns or seek clarification before withholding the medication. Interviews with the DON and the physician confirmed that the medication should not have been held without a specific order or parameters, and that the provider was not informed of the nurses' actions. For another resident, insulin glargine (Lantus) was administered on several occasions even when the resident's blood sugar was below the ordered threshold for holding the medication. The physician's order specified to hold Lantus if blood sugar was less than 150, but the medication was still given at lower blood sugar readings. Nursing staff interviews revealed a lack of awareness or attention to the specific parameters in the order, with some staff admitting to not reading the full order or making errors in administration. The facility's policy required medications to be administered as ordered by the physician, but this was not followed in these cases.