Failure to Administer Medications According to Physician Orders
Penalty
Summary
Facility staff failed to implement physician orders for three residents, resulting in deficiencies related to medication administration. For one resident with diabetes, a registered nurse administered 10 units of Lantus insulin instead of the ordered 9 units during a medication pass observation. The nurse confirmed the administration and stated she checks orders multiple times due to the high-risk nature of insulin, but the dose given did not match the physician's order. Facility policy requires checking the order and the five rights of medication administration at multiple points, but this was not followed in this instance. Another resident with hypotension received Midodrine despite physician orders to hold the medication if systolic blood pressure exceeded 120. The medication administration record showed the resident received Midodrine on several occasions when blood pressure readings were above the specified threshold, and in one instance, no blood pressure was recorded prior to administration. The unit manager reviewed the orders and records, confirming that the medication should not have been given under these circumstances. A third resident with end-stage renal disease and diabetes did not receive insulin as ordered according to a sliding scale protocol. The medication administration records indicated that insulin was not administered at multiple times when blood glucose levels required it per the sliding scale order. The unit manager acknowledged that the order should have been clarified, and failure to do so led to improper administration. Facility policy requires medications to be administered safely and as ordered, but this was not adhered to in these cases.