Failure to Administer and Document Medications per Physician Orders
Penalty
Summary
The facility failed to ensure that a resident received medications as ordered by the physician, specifically regarding the administration of Midodrine HCl and Novolog FlexPen insulin. The physician's order for Midodrine HCl required the medication to be held if the resident's systolic blood pressure (SBP) exceeded 130. However, medication administration records (MARs) showed instances where the medication was administered when the SBP was above the ordered parameter, and there were also occasions where documentation of blood pressure and nursing notes were missing when the medication was held or administered. Additionally, there were no progress notes explaining the rationale for holding or administering the medication outside of parameters, nor was there evidence of physician notification as required by the order and facility policy. For Novolog FlexPen insulin, the resident had orders for both scheduled doses and sliding scale administration. The MARs revealed multiple instances where insulin doses were held, omitted, or not documented, and in several cases, there were no corresponding progress notes or documentation of physician notification. Blood sugar readings were sometimes recorded as low or within a range that would typically require physician notification, but there was no evidence in the medical record that the physician was contacted or that a clinical decision was documented. Staff interviews confirmed that the expectation was to notify the physician and document actions taken when insulin was held due to low blood sugar, but this was not consistently done. The resident involved had a history of orthostatic hypotension and brittle diabetes mellitus, requiring careful monitoring and adherence to medication parameters. The lack of documentation, failure to follow physician orders, and absence of communication with the physician regarding medication administration and blood sugar results contributed to the deficiency. The facility's own policy required timely administration of medications as prescribed and appropriate documentation, which was not followed in these instances.