Failure to Adhere to Professional Standards in Medication Management
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality in three separate cases involving medication management and adherence to physician orders. In the first case, a resident with end stage renal disease, depression, and diabetes was admitted with a hospital discharge summary that included an order for lorazepam gel to be applied topically every 24 hours as needed for anxiety. Despite this, the lorazepam gel was not transcribed into the electronic medical record (EMR) or the medication administration record (MAR) from the time of admission until over two months later. Interviews revealed that both the admitting nurse and the Director of Nursing expected the medication to be processed and clarified with the provider if there were questions, but this did not occur, resulting in the omission of the medication from the resident's regimen. In the second case, a resident with hypertension and a history of cerebral infarction had an active order for Metoprolol, a medication that lowers heart rate and blood pressure. During medication administration, a nurse prepared to give Metoprolol to the resident despite a recorded heart rate of 46 beats per minute, which is below the normal range. The nurse did not have parameters to hold the medication and was unaware that Metoprolol should not be administered with a low heart rate unless directed by a provider. The nurse practitioner intervened before administration, instructed the nurse to hold the medication, and subsequently wrote an order to clarify the parameters for holding Metoprolol. In the third case, a resident with severe pain and a left knee contracture had a physician's order for a lidocaine patch to be applied in the morning and removed at bedtime. Observation revealed that the patch was not removed at bedtime as ordered, and the nurse responsible had documented its removal without actually performing the task. The nurse later could not recall if the patch had been removed, and the Director of Nursing confirmed that the order was not followed. These incidents demonstrate failures in medication transcription, administration, and adherence to physician orders for multiple residents.