Failure to Administer Medications as Ordered and Notify Providers of Held Doses
Penalty
Summary
Facility staff failed to meet professional standards of practice for three residents by not administering medications as ordered and not notifying providers when medications were held due to possible adverse effects. For one resident with hypertensive heart disease and heart failure, staff held blood pressure medications multiple times without provider notification, despite the absence of physician-ordered parameters for holding these medications. Documentation was inconsistent, with missing blood pressure readings and unclear reasons for withholding medications. Another resident with hypertensive heart disease without heart failure had a blood pressure medication order with specific parameters for holding the medication. However, staff frequently held the medication outside of these parameters, failed to document required blood pressure and heart rate readings, and did not consistently notify the provider when the medication was withheld. There were also instances where the medication was not administered even though the documented vital signs were within the parameters to give the medication, and staff did not document communication with the provider regarding missed doses due to appointments or low readings. A third resident with type 2 diabetes mellitus and hyperglycemia experienced multiple instances where insulin was not administered as ordered, including when the medication was not available or when blood sugar was low, despite the absence of hold parameters in the physician's order. Staff did not follow the facility's diabetic management policy for hypoglycemia, as there was no documentation of providing fast-acting sugar, rechecking blood glucose, or notifying the provider after low blood sugar episodes. The DON confirmed that staff did not notify providers about held medications and did not follow established protocols for medication administration and documentation.