Failure to Follow Physician-Ordered Medication Parameters
Penalty
Summary
The facility failed to follow physician-ordered parameters for medication administration for a resident with diagnoses of hypertension and diabetes mellitus. The resident, who had severe cognitive impairment and required substantial assistance with daily activities, had specific medication orders that included hold parameters for blood pressure, heart rate, and blood glucose levels. Despite these orders, the Medication Administration Records (MAR) for June and July 2025 showed that anti-hypertensive and diabetic medications, including amlodipine, propranolol, hydralazine, glimepiride, and insulin, were administered on multiple occasions when the resident's vital signs or blood glucose levels were outside the prescribed parameters. Interviews with licensed nursing staff and administrative staff confirmed that medications should not be given outside of ordered parameters and that any deviation should be communicated to the physician, with documentation of the physician's instructions. However, there was no evidence provided of such communication or documentation when medications were administered outside the parameters. Additionally, the facility did not provide a policy related to following physician-ordered parameters for medication administration.