Failure to Prevent Significant Medication Errors for Residents with Hypertension
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically for two residents who were reviewed for unnecessary medications. For one resident with essential hypertension and hypertensive heart disease, the physician's order required administration of Entresto twice daily. However, the medication was withheld on multiple occasions by a medication aide, who applied blood pressure parameters from other hypertension medications to Entresto, despite the absence of such parameters in the physician's order. There was no documentation in the resident's progress notes explaining why Entresto was withheld, and the prescribing provider was not always notified when the medication was not administered. Interviews with staff revealed that the medication aide held the Entresto based on her own interpretation of blood pressure readings and existing parameters for other medications, rather than following the specific physician's order for Entresto. The licensed vocational nurse confirmed instructing the aide to hold the medication in some instances due to low blood pressure, and acknowledged that the physician's order should have included administration parameters. The Director of Nursing stated that if medications are held due to nursing judgment, a progress note should be documented and the provider notified, which did not occur in these cases. For another resident with severe cognitive impairment and hypertension, the care plan did not address the hypertension diagnosis. The resident had an order for Metoprolol with specific parameters to hold the medication if blood pressure or pulse was below certain thresholds. Despite this, staff administered Amlodipine Besylate to the resident on numerous occasions when blood pressure readings were outside the prescribed parameters. The Director of Nursing was unaware of these out-of-parameter administrations and stated that her expectation was for parameters to be followed and for necessary parties to be informed if medications were given outside of parameters. Facility policies required adherence to medication administration standards and reporting of medication issues, which was not followed in these instances.