Failure to Follow Medication and Monitoring Protocols for Two Residents
Penalty
Summary
The facility failed to ensure that professional standards were met for two residents in relation to medication administration and monitoring. For one resident with heart failure, the facility did not document blood pressure readings as required when administering antihypertensive medication, despite provider orders specifying to hold the medication if blood pressure readings were below certain parameters. There were also periods where no blood pressure readings were documented at all, and staff interviews confirmed that the expectation was to follow the provider's orders and document the necessary parameters. Additionally, the same resident experienced constipation, and the facility did not follow its own bowel protocol. The resident went several days without a bowel movement, but the prescribed sequence of interventions—such as administering Milk of Magnesia, a glycerin suppository, and an enema—was not followed or documented. Staff interviews indicated that nurses were expected to monitor bowel movements and administer medications according to the protocol, but this did not occur. For another resident with diabetes, the facility failed to notify the medical provider when the resident's blood sugar levels exceeded the ordered parameters on multiple occasions. The resident's orders required provider notification for blood sugar levels above 400, but there was no documentation of such notifications in the medical record. Staff confirmed that they were educated to follow these parameters and document provider notifications, but this was not done in these instances.