Failure to Adhere to Medication Administration Parameters and Documentation
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by multiple instances where medications were administered outside of physician-ordered parameters or without proper documentation. For several residents with diagnoses such as hypertension, heart failure, and autonomic nervous system disorders, medications including Metoprolol, Digoxin, Lisinopril, Amlodipine, Losartan Potassium, and Propranolol were either given when vital signs were below the required thresholds or held without appropriate documentation of the reason. In some cases, vital signs were not taken as required before or after medication administration, and there was a lack of documentation in the medical records or progress notes to justify these actions. For example, one resident received Metoprolol despite a systolic blood pressure (SBP) below the ordered parameter, while another received Lisinopril and Metoprolol when their SBP was below the physician's specified threshold. In another case, a resident was given Amlodipine and Losartan Potassium outside the ordered SBP parameters. Additionally, there were instances where PRN Propranolol was administered without clear documentation of whether vital signs were taken before and after administration, as required by the provider's order. Interviews with nursing staff and the Director of Nursing Services confirmed that the expectation was for nurses to follow medication parameters and document vital signs accordingly. However, the facility's state reporting log did not reflect that these medication errors had been identified, and staff acknowledged that audits of medications with parameters were not routinely conducted. The lack of adherence to physician orders and incomplete documentation contributed to the identified deficiencies.