Failure to Follow Physician-Ordered Medication Parameters
Penalty
Summary
Surveyors identified that the facility failed to ensure residents' drug regimens were free from unnecessary drugs by not adhering to physician-ordered parameters for administering blood pressure and diabetic medications. For one resident with multiple complex diagnoses, including heart failure and diabetes, nursing staff administered Carvedilol even when the resident's heart rate was below the physician-ordered threshold, and failed to administer insulin as ordered when blood sugar was elevated, without documentation of physician notification or new orders. The Medication Administration Records (MAR) and nursing notes confirmed these deviations from prescribed parameters. Similar deficiencies were found for two other residents with significant medical histories, including neurological and cardiovascular conditions. In these cases, medications such as Propranolol, Hydralazine, and Metoprolol were administered or withheld contrary to specific physician orders based on blood pressure and heart rate readings. The Director of Nursing (DON) confirmed these findings during record reviews and acknowledged a recurring issue with staff not following physician-ordered medication parameters on the affected unit.