Failure to Administer Medications as Ordered by Physicians
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of medications as ordered by physicians for two residents. For one resident with a history of protein-calorie malnutrition, hypertension, and chronic ischemic heart disease, the medication aide administered only 1,000 units of vitamin D instead of the physician-ordered 2,000 units. The medication aide acknowledged the error, stating it was a mistake and that she believed she was following the order at the time. The resident's care plan included interventions to give medications as ordered, but the full prescribed dose was not administered. For another resident with hypertension and hypertension urgency, staff failed to follow physician-prescribed parameters for administering Clonidine, a medication used to lower blood pressure. The physician's order specified that Clonidine should be given only when the systolic blood pressure (SBP) was greater than 160. However, the medication was administered on multiple occasions when the resident's SBP was below this threshold. Medication aides involved in these incidents admitted to not holding the medication as required and attributed the errors to oversight and not reading the order carefully. Interviews with staff, including medication aides and the Director of Nursing, confirmed that medications were not always administered according to physician orders and established parameters. The facility's policy required medications to be administered in accordance with written physician orders, but this was not consistently followed, resulting in medication errors for both residents.