Failure to Ensure Physician Parameters and Indications for Medication Administration
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary medications by not following physician parameters for a prescribed antihypertensive medication and by administering medications without documented indications. Specifically, the resident’s electronic medical record showed orders for Ursodiol and Tamsulosin that lacked indications for administration. Additionally, the order for Metoprolol succinate, an antihypertensive, included a directive to hold the medication if the systolic blood pressure was less than 110 mm Hg or the heart rate was less than 60 beats per minute, but there was no evidence that heart rate monitoring was consistently performed as ordered. Review of the resident’s Medication Administration Record and other documentation over a 100-day period revealed that heart monitoring was not documented for 61 days, despite the physician’s order requiring it prior to administration of Metoprolol. The Monthly Medication Reviews from the pharmacy also failed to identify or address the lack of indications for certain medications and the absence of required heart monitoring for the antihypertensive medication. The care plan and facility policy required staff to administer medications as ordered and to ensure every medication had an appropriate indication, but these requirements were not met in this case. Interviews with nursing staff and administration confirmed that all medications should have a documented indication and that physician parameters, such as heart rate monitoring, should be followed. Despite these expectations and policies, the facility did not ensure compliance, resulting in the administration of medications without proper indications and without following monitoring parameters as ordered by the physician.