Failure to Follow Medication Administration Parameters and Orders
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and established parameters for two residents. For one resident with diagnoses including hypertension and congestive heart failure, digoxin and metoprolol were administered despite physician orders specifying that these medications should be held if the resident's pulse was below 60 beats per minute. Documentation showed that on multiple occasions, both medications were given when the resident's pulse was below the prescribed threshold. The Director of Nursing confirmed that these medications should have been withheld under those circumstances. For another resident with a history of substance use and major depressive disorder, insulin orders were not followed as prescribed. The resident was to receive both fast-acting and long-acting insulin at specific times, but the Medication Administration Record indicated several missed doses without documentation explaining the omissions. The Nurse Consultant was unable to provide any reason for the missed insulin administrations. The facility's Medication Administration Policy required vital signs to be obtained as necessary and medications to be administered as ordered, but these procedures were not followed in these cases.