Failure to Administer Medications According to Physician Orders
Penalty
Summary
Facility nursing staff failed to administer medications according to physician orders for two residents. For one resident, the physician ordered Metoprolol 50 mg to be given twice daily, with instructions to hold the medication if the systolic blood pressure was less than 110 or the heart rate was less than 60. On two occasions, the medication was administered despite the resident's blood pressure being below the specified threshold or not being checked at all prior to administration. There were no progress notes documenting the rationale for administering the medication against the ordered parameters. For another resident, the physician ordered Oxycodone 5 mg to be given every six hours as needed for pain, only if the resident rated their pain between 5 and 10 on a 0 to 10 scale, and to hold for sedation, decreased respirations, or altered mental status. The medication was administered on three occasions when the resident reported a pain level of 4, which was outside the ordered parameters. The DON acknowledged these findings during an interview and was uncertain about when staff education on this issue had last occurred.