Failure to Administer Medication as Ordered and Notify Physician
Penalty
Summary
A deficiency occurred when nursing staff failed to administer Entresto, a blood pressure medication, as ordered by the physician for a resident with diagnoses including end stage renal disease, chronic systolic congestive heart failure, type 2 diabetes mellitus with diabetic chronic kidney disease, and essential primary hypertension. The physician's order specified that Entresto should be given twice daily, but the medication administration record showed that doses were withheld on multiple occasions, marked as 'outside parameters,' without any documented parameters for withholding the medication. Nursing and medication administration notes for the relevant period did not contain documentation that the physician was notified when the medication was not administered. Interviews with the RN and LPN involved revealed that they held the medication due to low blood pressure, despite the absence of specific parameters in the order, and did not notify the physician or document the rationale as required by facility policy. The facility's policy states that if a drug is withheld, the reason must be documented and the physician and responsible party notified, which was not done in this case.