Failure to Ensure Drug Regimens Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure that each resident’s drug regimen was free from unnecessary medications, as evidenced by two separate incidents involving two residents. One resident, a male with a history of heart valve replacement, pacemaker, and congestive heart failure (CHF), was administered Eliquis, a blood thinner, without an appropriate diagnosis documented in the facility records. The hospital records indicated Eliquis was given for a pacemaker, while the facility’s physician orders listed CHF as the indication. During interviews, staff were unable to confirm the correct diagnosis for the medication, and the Director of Nursing (DON) clarified that Eliquis should be indicated for atrial fibrillation or pacemaker, not CHF. Another resident, a female with diagnoses of hypertension urgency and essential hypertension, received Clonidine, an antihypertensive medication, outside of the prescribed parameters. The physician’s order specified that Clonidine should be administered only if the systolic blood pressure (SBP) was greater than 160. However, medication administration records showed that the medication was given on multiple occasions when the resident’s SBP was below this threshold. Medication aides involved acknowledged during interviews that the medication should have been held according to the parameters and attributed the errors to oversight and not reading the order carefully. Facility policy required medications to be administered in accordance with written physician orders. Despite this, the staff failed to follow the specified parameters for medication administration and did not ensure that medications were given only with appropriate indications. These actions resulted in the administration of unnecessary medications and doses, as documented in the residents’ records and confirmed by staff interviews.