Failure to Administer Medications and Labs per Physician Orders
Penalty
Summary
The facility failed to administer blood pressure medications and laboratory tests according to physician orders and established parameters for three residents. For one resident with end stage renal disease, hypotension, and hypertension, the care plan required medications to be given per physician order, including Midodrine HCl to be held if systolic blood pressure was less than or greater than 110 or heart rate was less than 60. However, the medication was administered on multiple occasions when the resident's blood pressure readings were outside the specified parameters, and the DON acknowledged the need for order clarification. Another resident with Alzheimer's disease, hypertensive heart disease, and hypotension had orders for Lisinopril to be held if blood pressure was less than 100/60, and for PRN Midodrine if systolic blood pressure was less than 90. The resident received Lisinopril on several occasions when blood pressure was below the hold threshold, and did not receive PRN Midodrine when blood pressure was low enough to warrant it. Additionally, blood pressure monitoring was not performed at the frequency specified in the order. The DON confirmed that the medication administration did not follow the orders and that clarification should have been obtained. A third resident with hemiplegia, diabetes, and atrial fibrillation had handwritten orders for repeat laboratory tests and potassium administration, but these were not entered into the electronic record. There was no evidence that the repeat lab was completed or that potassium was given as ordered. The DON confirmed that these actions were not carried out as required.