Failure to Administer Medications as Ordered and Inadequate Documentation
Penalty
Summary
The facility failed to ensure that insulin and hypotensive medications were administered according to physician orders for multiple residents. For several residents with diabetes mellitus, long-acting insulin was not administered as ordered, with staff documenting codes indicating the medication was not required or was held, despite the absence of physician parameters allowing for such actions. Medication Administration Records (MARs) showed repeated instances where insulin doses were omitted, and nursing progress notes lacked documentation explaining the rationale for withholding the medication. Interviews with LPNs revealed a misunderstanding of when to hold long-acting insulin, with some staff stating they used their own judgment or believed parameters existed when they did not. The Director of Nursing confirmed that there were no orders to hold the long-acting insulin, and the expectation was for staff to follow physician orders. In addition to the insulin administration issues, the facility failed to administer midodrine, a medication for hypotension, as ordered for a resident with low systolic blood pressure. Despite multiple documented instances of systolic blood pressure readings below the physician-ordered threshold, the medication was not given. Staff interviews indicated confusion regarding the parameters for administering midodrine, with one LPN stating they focused on diastolic rather than systolic blood pressure and referencing facility in-service training that may have contributed to the misunderstanding. The DON acknowledged that the nurse involved was confused about the correct parameters and that staff are expected to follow provider orders. Across all cases, there was a lack of appropriate documentation in the medical records to justify withholding medications, and staff interviews consistently revealed gaps in knowledge or misinterpretation of physician orders. The deficiencies were identified through review of physician orders, MARs, nursing progress notes, and staff and physician interviews, all of which confirmed that medications were not administered as prescribed and that documentation and communication with providers were insufficient.