Failure to Follow Physician Orders Resulting in Medication Administration Errors
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents remained free from significant medication errors by not following physician orders and its own medication administration policy. For one resident, the physician’s order dated 2/16/24 directed Hydralazine 50 mg to be given every 8 hours at 6 a.m., 2 p.m., and 10 p.m., with instructions to hold the dose only if blood pressure was below 100/60. On 7/29/25 at 1:12 p.m., an LPN obtained the resident’s blood pressure as 108/70 prior to the scheduled 2 p.m. Hydralazine dose. When asked, the LPN stated she was going to hold the Hydralazine and call the physician so the resident’s blood pressure would not go too low. After the surveyor questioned whether there were parameters to hold the medication, the LPN reviewed the EMAR and confirmed the order specified to hold only if blood pressure was below 100/60, which it was not at the time. For another resident with glaucoma, physician orders dated 7/26/25 included Simbrinza eye drops, one drop to the left eye three times daily at 9 a.m., 1 p.m., and 9 p.m., and Latanoprost eye drops, one drop to both eyes at bedtime. On 7/28/25 at 12:22 p.m., the resident reported not having received the morning Simbrinza eye drops. At 12:31 p.m., when the surveyor asked why the 9 a.m. eye drops had not been given, an LPN reviewed the EMAR and stated the resident received eye drops at 9 p.m., referring to Latanoprost, and initially affirmed the resident did not have another eye drop prescribed. At 12:50 p.m., the resident reported receiving the Simbrinza a few minutes earlier, indicating the 9 a.m. dose was administered roughly three hours late. The facility’s medication administration policy dated 10/25/14 states that medications are to be administered in accordance with written prescriber orders, which did not occur in these instances.
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