Failure to Adhere to Medication Administration Parameters and Documentation Standards
Penalty
Summary
The facility failed to follow professional standards of practice in medication administration for three residents with diagnoses including congestive heart failure (CHF) and hypertension (HTN). For one resident, there was no documentation that blood pressure (BP) or heart rate (HR) were monitored prior to administering eight of eleven doses of Carvedilol, despite physician orders requiring these checks. Staff interviews confirmed that vital signs should be checked and documented before administering medications with parameters, but records showed missing documentation for multiple doses. Another resident received Carvedilol and Hydralazine outside of the physician-ordered parameters on several occasions, with missing documentation of HR for five of nine doses and administration of medications when vital signs were outside the specified limits. Staff acknowledged the expectation to document and review vital signs before medication administration, but also stated that there was no routine audit for medications given outside parameters, and errors were only addressed if discovered incidentally. A third resident was administered Metoprolol and Midodrine outside of the established parameters, as evidenced by the medication administration record (MAR) showing doses given when systolic blood pressure was below or above the ordered thresholds. Staff confirmed that medications had been administered outside of parameters but were unable to fully review all relevant dates due to difficulties navigating the electronic record system. These failures to adhere to physician orders and document required assessments led to the identified deficiencies.