Failure to Administer Ordered Medication Prior to Dialysis
Penalty
Summary
Facility staff failed to prevent significant medication errors for one resident who was receiving dialysis. According to physician orders, the resident was to receive Midodrine as needed for hypotension prior to dialysis, provided their systolic blood pressure was below 140. Review of clinical records, hemodialysis communication records, and electronic medication administration records (eMARs) showed that on multiple occasions, the resident's blood pressure was within the parameters for administration, but there was no documentation that the medication was given before dialysis. The care plan for the resident included instructions to administer medications as ordered and to monitor for side effects and effectiveness, but these interventions were not followed as documented. Interviews with facility staff, including an LPN and the medical doctor, confirmed that the expectation was for Midodrine to be administered on dialysis days when the resident's blood pressure was below 140. The facility's policy required medications to be administered safely, timely, and as prescribed, but this was not adhered to in this case. The deficiency was brought to the attention of the administrator, director of nursing, and regional clinical nurse, with no further information provided prior to the survey exit.