Failure to Follow Professional Standards in Medication Administration
Penalty
Summary
The facility failed to follow professional standards of quality in medication administration for three residents. One resident with diabetes mellitus was given an incorrect dose of insulin after a nurse read the wrong record, resulting in the resident being sent to the emergency room for monitoring due to the risk of hypoglycemia. Another resident with type 2 diabetes mellitus received insulin doses outside of the prescribed blood sugar parameters on multiple occasions, with no documentation of the rationale for administering the medication outside of those parameters or any provider order authorizing such administration. Additionally, this resident was not included on the list of orders with parameters for holding medications in the nurse binder. A third resident with hypertension received Losartan despite blood pressure readings that were outside the parameters set by the provider's order, or without a blood pressure assessment prior to administration. There was no documentation explaining the rationale for administering Losartan outside of the prescribed parameters or any provider order to do so. This resident was also not included on the list of orders with parameters for holding medications in the nurse binder. These findings were based on interviews, record reviews, and review of medication administration records.