Failure to Follow Medication Administration Parameters and Documentation Procedures
Penalty
Summary
A deficiency occurred when the facility failed to provide pharmaceutical services that ensured the accurate administration and documentation of medications for a resident with multiple complex diagnoses, including acute kidney failure, secondary malignancies, and hypertension. The resident had a physician's order for Cozaar (Losartan Potassium) with specific parameters to hold the medication if the systolic blood pressure (SBP) was less than 120 or the diastolic blood pressure (DBP) was less than 60, or if the pulse was less than 60. Despite these clear parameters, medication administration records (MAR) indicated that the medication was signed as administered on three separate days when the resident's blood pressure readings were below the ordered thresholds. Interviews with the medication aides (MAs) responsible for administering the medication revealed that on each occasion, the staff either did not administer the medication due to the resident being out of parameters but still signed the MAR as if it had been given, or in one case, administered the medication despite the resident being out of parameters, after which the resident spit out the medication. The MAs did not consistently notify a nurse when the medication was held or refused, and documentation on the MAR did not accurately reflect the events. The staff cited reasons such as being rushed, forgetting to document, or assuming standard parameters, and acknowledged that their actions did not align with facility policy or physician orders. The Director of Nursing (DON) confirmed that the staff did not follow the required procedures for checking parameters, documenting accurately, and notifying nursing staff when medications were held or refused. The DON also verified that all three staff members had received training and competency assessments related to medication administration, including following parameters and proper documentation. However, the failure to adhere to these protocols resulted in inaccurate MAR documentation and a lack of appropriate communication regarding the resident's medication administration.