Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
Staff failed to follow physician orders for two residents with complex medical conditions, including end stage kidney disease, diabetes mellitus, and hypertension. For one resident, insulin (Lispro) was administered multiple times when blood sugar levels were below the physician-ordered threshold of 100 mg/dL. For another resident, insulin was given on several occasions when blood sugar was below the ordered threshold of 120 mg/dL. Additionally, blood pressure medications were administered outside of the specified parameters, including giving hydrochlorothiazide and metoprolol when the resident's systolic blood pressure was below the ordered limits. There were also instances where staff did not obtain or record required blood pressure or heart rate measurements prior to administering these medications, as directed by the physician's orders. The Director of Nursing confirmed that medications were administered outside of the established parameters and that there was no evidence of required vital sign documentation prior to medication administration for the affected resident. These findings were based on clinical record review and staff interviews, and were cited as violations of nursing service regulations.