Failure to Adhere to Medication Administration Parameters
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident was free from significant medication errors. The resident, who had diagnoses including muscle wasting and atrophy, COPD, type 2 diabetes, hypothyroidism, and hypertension, was prescribed Hydralazine HCl with specific parameters: the medication was to be held if the systolic blood pressure was less than 110, diastolic blood pressure was less than 60, or heart rate was under 60 beats per minute. Despite these parameters, the medication was administered on four occasions when the resident's diastolic blood pressure was below 60. Record review showed that the medication was given outside of the prescribed parameters by two LVNs on multiple dates. The facility's medication administration policy did not include guidance regarding medication parameters. During an interview, the DON stated that medications should be given within parameters and that staff should contact the physician if parameters are unclear.