Failure to Adhere to Medication Administration Standards for Two Residents
Penalty
Summary
Facility staff failed to provide services that meet professional standards of quality for two residents. For one resident with a diagnosis of unspecified atrial fibrillation and an order for Digoxin, staff did not document the apical pulse prior to administering the medication, as required by both physician order and standard nursing practice. The Medication Administration Record (MAR) showed Digoxin was given daily at 9:00 a.m., but no apical pulse reading was recorded at that time. Although apical pulse readings were documented twice daily, they were not specifically taken or recorded immediately before the Digoxin dose, and the Interim Director of Nursing confirmed this omission during interview and record review. In a separate incident, another resident with an order for Carvedilol to be held if systolic blood pressure was less than 105 or pulse less than 55 was administered the medication despite a recorded diastolic blood pressure of 50 mmHg, which is considered low. The nurse did not recheck the blood pressure or consult the physician prior to administration. The Interim Director of Nursing verified the physician order and the low diastolic blood pressure reading prior to medication administration, acknowledging that the nurse should have taken additional steps before giving the medication. Facility policy requires vital signs to be checked and verified prior to medication administration when necessary.