Failure to Follow Physician Orders and Medication Administration Protocols
Penalty
Summary
Surveyors identified that the facility failed to ensure physicians' orders were followed for two of three residents reviewed for medication administration. In one instance, a medication cup with pills was observed on a resident's bedside table, and the resident stated she delays taking her medications until after breakfast. Review of her clinical record showed multiple diagnoses, including hypertensive heart disease, chronic kidney disease, Parkinson's disease, and diabetes. The electronic medication administration record (EMAR) revealed several instances where blood pressure readings were not recorded, and medications were not signed as given, with code 4 (vitals outside parameters) used despite no physician's order specifying parameters for holding the medication. Additionally, another resident reported that medications were left on her over-bed table, and she took them without staff present, sometimes receiving additional medications shortly after. Interviews with staff confirmed that medications were sometimes left unattended at the bedside, contrary to facility policy, which requires staff to observe medication consumption and prohibits leaving medications unless the resident has been assessed for safe self-administration. Staff also indicated uncertainty regarding physician orders for holding medications based on vital signs.