Failure to Administer and Document Medications as Ordered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not administering prescribed medications as ordered. On one occasion, amlodipine besylate, a medication used to manage blood pressure, was administered to the resident despite the resident's blood pressure being below the parameters specified in the physician's order. The medication was given when the systolic blood pressure was 108, which was below the hold parameter of 120, and there was no documentation explaining the rationale for administering the medication outside of these parameters. Additionally, on another occasion, the resident did not receive a total of 14 prescribed medications at the scheduled administration time. The medications missed included treatments for blood pressure, seizure management, supplements, and other chronic conditions. The Medication Administration Record (MAR) for that day showed that the medications were not signed off as given, and there was no documentation to indicate the reason for the omission, such as resident refusal or difficulty swallowing, nor was there evidence that the physician was notified of the missed doses. The resident involved had a complex medical history, including vascular dementia, hyperlipidemia, hypertensive heart disease, seizures, and hemiplegia following a cerebral infarction. The facility's policy required medications to be administered as prescribed and within a specific time frame, with documentation for any deviations. The lack of documentation and failure to follow physician orders led to the identified deficiency.