Failure to Administer Medications Within Ordered Parameters
Penalty
Summary
The facility failed to ensure that medications were administered within physician-ordered parameters for two residents, resulting in a deficiency related to unnecessary drug use. One resident with diabetes mellitus, who was cognitively intact and on a therapeutic diet, had a physician's order for fast-acting insulin to be held if blood sugar was less than 100 mg/dL. Despite this, the resident received insulin on multiple occasions when blood sugar readings were below the ordered threshold, as documented by both the consultant pharmacist and the Medication Administration Record. There was also a lack of documentation on one occasion regarding whether the medication was administered or if blood sugar was checked. Another resident with a history of stroke, hypertension, and sleep apnea had physician's orders for antihypertensive medications (amlodipine and metoprolol) with specific parameters to hold the medications if blood pressure or heart rate fell below certain levels. The resident received these medications on several occasions when blood pressure readings were below the ordered parameters, as identified in both the consultant pharmacist's review and the Medication Administration Record. The care plan for this resident included monitoring for medications with Black Box Warnings and reporting concerns to the physician, but the administration of medications outside of parameters still occurred. Staff interviews confirmed that nurses were expected to follow medication parameters before administration, and that some staff had received training after errors were identified. However, the education was only provided to staff who had been found to administer medications incorrectly, rather than all staff. The facility's Medication Management policy required ongoing monitoring to ensure drug regimens were free from unnecessary drugs and that medications were administered safely and effectively, but this was not consistently followed for the residents involved.