Failure to Administer PRN Medication per Physician Order
Penalty
Summary
The facility failed to ensure that physician orders for medication administration were followed for a resident with multiple complex diagnoses, including osteoarthritis, schizoaffective disorder, severe malnutrition, cognitive communication deficit, and a stage 4 pressure ulcer. The resident had a physician order for Midodrine HCL 5 mg to be administered orally every six hours as needed for blood pressure readings less than 110/60 mmHg. Review of the resident's vital signs over several weeks showed multiple instances where blood pressure readings fell below the ordered threshold, but the medication was not administered as prescribed. Further review of the medication administration record confirmed that no doses of midodrine were given during the period in question, despite qualifying blood pressure readings. Interviews with two registered nurses revealed that they were either unaware of the order or did not notice it, and both acknowledged that the medication should have been administered according to the physician's parameters. This failure to follow physician orders resulted in the resident not receiving the prescribed treatment for low blood pressure.