Failure to Follow Physician-Ordered Monitoring Parameters During Medication Administration
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary medications by not following physician-ordered monitoring parameters during medication administration. For one resident with diagnoses of congestive heart failure (CHF) and high blood pressure, staff administered metoprolol tartrate despite physician orders to hold the medication if the resident’s systolic blood pressure was 110 mm/Hg or less or if the heart rate was below 65 beats per minute. Documentation showed that the medication was given multiple times when the resident’s heart rate was below the ordered threshold, with recorded heart rates as low as 42 beats per minute. Another resident with CHF and orthostatic hypotension had a physician order for Entresto, with instructions to hold the medication if the standing systolic blood pressure was less than 100 mm/Hg. Staff administered this medication twice daily over a period of several weeks without consistently checking or documenting the resident’s blood pressure prior to administration, as required by the order. The vital sign summary indicated that blood pressure was only recorded once during this period, and staff interviews confirmed a lack of awareness and compliance with the monitoring requirements. Interviews with facility staff, including a Certified Medication Technician, an LPN, the Director of Nursing, and the Administrator, revealed inconsistent understanding and implementation of the policy regarding medication administration with vital sign parameters. Staff acknowledged that vital signs should be checked and documented on the medication administration record (MAR) when required by physician orders, but there was no designated place on the MAR for this documentation, and the required monitoring was not consistently performed.