Failure to Administer Medications According to Ordered Parameters and Unnecessary Drug Use
Penalty
Summary
Facility staff failed to ensure that residents received medications according to physician-ordered parameters, resulting in the administration of unnecessary drugs. For one resident, Atenolol was administered on multiple occasions despite the resident's systolic blood pressure being below the ordered threshold of 110, and Humalog insulin was given even when the resident's blood sugar was below the ordered hold parameter of 100. These actions were confirmed through clinical record review and acknowledged by the Director of Nursing, who stated that administering insulin outside of parameters was an ongoing issue among nursing staff. Additionally, another resident was prescribed oxycodone to be administered as needed for moderate pain, defined as a pain score of 4-7. However, staff administered oxycodone when the resident's documented pain scores were below the ordered threshold, with pain assessments recorded as 2 or 3 at the time of administration. The Director of Nursing confirmed that the pain medication was not administered according to the physician's parameters, as evidenced by the medication administration records and pain assessments.