Failure to Administer Dialysis Resident's Medications as Ordered
Penalty
Summary
The facility failed to administer medications according to physician's orders for a resident receiving dialysis. Facility policy requires that medications be administered safely, timely, and as prescribed, including adherence to any required time frames. For a resident with diagnoses including hypertension, muscle weakness, type II diabetes, and end stage renal disease requiring regular dialysis, physician's orders specified Hydralazine 25 mg three times daily and Metformin 500 mg twice daily. Review of the Medication Administration Records for June and July showed that the resident did not receive the noon doses of Hydralazine and Metformin on multiple dates corresponding to dialysis days, with the reason documented as 'Not in Facility.' There was no documentation that the physician was notified regarding the need to hold or alter the administration times for these medications on dialysis days. During an interview, the Director of Nursing confirmed that the medications were not administered as ordered on those days. This failure to follow physician's orders and facility policy resulted in a deficiency under the cited nursing services regulation.