Failure to Document Required Parameters During Medication Administration
Penalty
Summary
The facility failed to ensure that specified parameters were obtained and recorded during medication administration for a resident with complex medical needs. The resident had multiple diagnoses, including tracheostomy, chronic respiratory status, ventilator dependence, dysphagia, hemiplegia, gastrostomy, epilepsy, pleural effusions, vascular dementia, Down Syndrome, end stage renal disease, and depression. The resident was non-communicative and had both short-term and long-term memory problems. Physician orders required that Midodrine, a medication for hypotension, be administered only if the systolic blood pressure was 120 mmHg or less, with instructions to hold the medication if the blood pressure exceeded this threshold. Review of the medication administration record revealed that multiple doses of Midodrine were given without documentation of corresponding blood pressure readings at the time of administration. Interviews with nursing staff and CNAs confirmed that while vital signs are typically obtained and documented, there was no consistent documentation of blood pressure readings specifically tied to the administration of medications with parameters. The Director of Nursing stated that nurses are expected to document vital signs prior to administering such medications, but there was no system trigger to require documentation when the vital sign is within parameters. Additionally, the facility was unable to provide a medication administration policy during the survey.