Failure to Follow Medication Hold Parameters and Insulin Pen Guidelines
Penalty
Summary
The facility failed to follow physician's orders regarding medication administration and did not adhere to manufacturer guidelines for insulin pen usage for five residents. For several residents with hypertension and hypotension, staff did not consistently assess or document required vital signs, such as blood pressure and heart rate, prior to administering cardiac medications with specific hold parameters. In multiple instances, medications were given even when residents' vital signs were outside the prescribed parameters, or without any documentation that the necessary assessments were performed. One resident with hypertension and chronic kidney disease received Metoprolol without documentation of blood pressure and heart rate assessments for the evening dose. Another resident with severe cognitive impairment and orthostatic hypotension was administered Midodrine without evidence that blood pressure was checked prior to each dose, as required. Additional residents received antihypertensive medications despite their blood pressure or heart rate being below the physician-ordered thresholds for holding the medication. In one case, a resident received Coreg and Lisinopril when their diastolic blood pressure or heart rate was below the specified limits. The facility also failed to follow manufacturer instructions for insulin pen administration. During an observation, an LPN administered Lantus insulin using a pen device without priming the pen as directed by the manufacturer. The manufacturer's insert specifies that a safety test (priming) must be performed before each injection to ensure proper dosing and pen function, but this step was omitted during the observed administration.