Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to follow physician's orders regarding medication administration for one resident. According to the facility's medication administration policy, staff are required to verify specific information, such as medication allergies and vital signs, prior to administering medications. For a resident with diagnoses including diabetes and hypertension, physician's orders specified that Metoprolol Tartrate should be held if the resident's heart rate was less than 60, and that Insulin Aspart should be held if the resident's blood glucose was less than 120 mg/dL. Review of the resident's Medication Administration Record (MAR) showed that there was no documented evidence that the resident's heart rate was checked prior to administering Metoprolol Tartrate over a period of several weeks. Additionally, Insulin Aspart was administered multiple times when the resident's blood glucose was below the threshold specified in the physician's order. These findings were confirmed by the Assistant Director of Nursing during interviews.