Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
Facility staff failed to follow physician orders for two residents. One resident with Alzheimer's disease and hypertension had a physician's order for Bisoprolol Fumarate to be administered three times daily, with instructions to hold the medication if the systolic blood pressure was below 90 mm/Hg or if the heart rate was less than 60 beats per minute. Despite these parameters, the medication was administered multiple times over several months when the resident's heart rate was below 60. Another resident with epilepsy, dementia, and hypertension had a physician's order for Hydralazine to be given every 8 hours as needed if the systolic blood pressure exceeded 140 mm/Hg. Staff failed to administer the medication on several occasions when the resident's blood pressure was above this threshold. These findings were confirmed by the Administrator during an interview.