Failure to Follow Professional Standards in Medication Administration and Monitoring
Penalty
Summary
The facility failed to ensure nursing practices met professional standards for three residents. For one resident with congestive heart failure, nursing staff administered Lasix daily as ordered to be held if systolic blood pressure (SBP) was below 100, but there was no documentation of SBP being checked prior to administration. The resident's clinical record showed only seven BP assessments over more than two months, and the facility's medication administration policy required vital signs to be recorded as indicated by medication orders. The Director of Nursing and Infection Preventionist confirmed that the system did not prompt staff to record BP before giving Lasix, and there was no documentation to support that BP was checked as required. Additionally, two residents received pain medications not in accordance with physician orders. One resident was given morphine for severe pain on five occasions when their pain score was zero, and another resident received Ultram for moderate to severe pain, but nine out of fifteen doses were given when the pain score was zero or not applicable. Both the DON and IP confirmed these medications were not administered as prescribed. Furthermore, for one resident with an elevated ammonia level, there was no documentation that the physician was notified of the abnormal result, despite facility policy requiring prompt notification of abnormal lab results. These failures resulted in medications not being given as ordered and inadequate monitoring or treatment of medical conditions.