Inaccurate Medication Administration Documentation and Failure to Follow Parameters
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for a resident, specifically regarding the administration of a physician-ordered antihypertensive medication. The resident, an older female with diagnoses including acute kidney failure, secondary malignant neoplasms, and hypertension, had a physician's order for Cozaar (Losartan Potassium) with specific parameters to hold the medication if systolic blood pressure was below 120 or diastolic below 60, or if pulse was below 60. On three consecutive days, medication administration records (MAR) were signed off by medication aides as if the medication had been administered, despite the resident's blood pressure readings being outside the prescribed parameters for safe administration. Interviews with the medication aides responsible for those days revealed that two of them did not administer the medication because the resident's blood pressure was out of range, but they erroneously documented it as given on the MAR. The third aide administered the medication despite the blood pressure being out of parameters, and the resident subsequently spit out the medication due to nausea. This aide also documented the medication as administered and did not make a note about the incident or notify a nurse. All three aides failed to notify nursing staff when the medication was held or refused, as required by facility policy and physician orders. The Director of Nursing confirmed that the medication should not have been administered on any of the three days based on the resident's blood pressure readings and that the documentation on the MAR was inaccurate. The facility's policy required staff to check vital signs, hold medication if parameters were not met, and accurately document administration or refusal, including notifying the nurse when medication was held or refused. Despite prior training and competency assessments, the staff did not follow these procedures, resulting in incomplete and inaccurate clinical records for the resident.