Failure to Identify and Report Medication Error
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to identify and report a medication error as required by its policy. A resident with an order for Lisinopril 2.5 mg, to be administered orally in the evening and held if the systolic blood pressure (SBP) was less than 120 mm Hg, received the medication despite having an SBP of 113 mm Hg documented on the Medication Administration Record. The medication order was not followed, and the error was not detected or reported to the Administrator or Director of Nursing (DON) for review and appropriate action. During an interview and concurrent review of the resident's records with the DON, it was confirmed that the medication should have been held and that the facility had not previously identified or reported the error.