Failure to Administer and Reorder Medications as Prescribed
Penalty
Summary
The facility failed to ensure that medications were administered as ordered for two residents. For one resident with a history of chronic obstructive pulmonary disease, hypertension, and other conditions, there was a physician's order to administer Olmesartan Medoxomil 20 mg daily, with instructions to hold the medication if the systolic blood pressure was 100 or less. Despite this, the medication was administered on multiple occasions without documentation of the resident's blood pressure at the time of administration. The Director of Nursing confirmed that blood pressures were not monitored when the medication was given, contrary to the physician's order and care plan interventions. Another resident, with diagnoses including right lower quadrant pain and schizoaffective disorder, had a physician's order for Norco 5-325 mg every six hours for pain. The resident's medical record and progress notes indicated that the Norco was not available for administration for several days, resulting in the resident receiving Tylenol instead, which was documented as ineffective for pain relief on at least one occasion. Staff notes repeatedly indicated that the Norco was on order or awaiting delivery, and the controlled drug record showed the last dose was administered several days prior. Nursing staff confirmed the resident had been without the prescribed pain medication for a week, and the nurse practitioner was unaware of the medication's unavailability. Facility policy required medications to be administered in a safe and timely manner as prescribed. The failure to monitor blood pressure prior to administering antihypertensive medication and the lack of timely reordering and availability of prescribed pain medication for the residents constituted non-compliance with pharmaceutical service requirements. These deficiencies were identified through medical record review, staff interviews, and policy review.