Failure to Follow Medication Administration Parameters and Physician Orders
Penalty
Summary
Staff failed to administer antihypertensive medications according to prescribed parameters for two residents with complex medical histories, including hypertension. For one resident, medications were given on multiple occasions despite blood pressure readings below the ordered threshold. Similarly, another resident received blood pressure medications outside of the specified heart rate and systolic blood pressure parameters on several occasions across two months. These actions were not in accordance with the medication administration records and physician orders. During medication pass observations, an agency LPN did not follow facility policy for resident identification, administering medications without confirming the resident’s identity using two identifiers. The same LPN was also observed storing pre-poured, unlabeled medication cups in the medication cart, and was unable to identify the contents of one of the cups. Facility policy required medications to be administered at the time they are prepared and for medication cups to be labeled if not immediately administered. Additionally, staff did not follow or clarify physician orders for two residents. One resident’s order for monthly weights was not completed for two consecutive months, with documentation either missing or incomplete. Another resident had conflicting as-needed pain medication orders and unclear bowel protocol orders, with no clarification provided to guide staff on which medications to administer first. These failures were confirmed by interviews with facility leadership, who stated that staff were expected to follow physician orders and facility policies.