Failure to Adhere to Physician-Ordered Medication Parameters and Timely Administration
Penalty
Summary
The facility failed to ensure that each resident’s drug regimen was free from unnecessary drugs, as defined by administration outside of physician-ordered parameters, missed doses, and lack of adequate monitoring. For three residents, there were documented instances where blood pressure medications were administered despite vital signs being outside the prescribed hold parameters. Specifically, one resident with hypertensive chronic kidney disease, hemiplegia, and atrial fibrillation received Metoprolol Tartrate on six occasions when either systolic blood pressure or heart rate was below the physician’s specified threshold for holding the medication. Another resident with diagnoses including orthopedic aftercare, diabetes, and morbid obesity did not receive her prescribed Dulaglutide injections as scheduled for three weeks following admission. The delay was attributed to pharmacy delivery issues and insurance coverage, with documentation showing missed doses and late administration. The resident reported the missed doses, and the nurse confirmed difficulties in obtaining the medication, but there was inconsistent documentation of physician notification and follow-up. A third resident with multiple cardiac conditions, including atrial fibrillation and congestive heart failure, received both Metoprolol Succinate ER and Amiodarone HCl on several occasions when blood pressure or heart rate was below the ordered parameters for holding the medications. Interviews with the DON confirmed that medications should have been held according to the physician’s orders, and that the administration outside of these parameters was not in compliance with the prescribed regimen.