Failure to Obtain and Administer Ordered Antihypertensive Medication at Admission
Penalty
Summary
The deficiency involves the facility’s failure to obtain and administer all ordered medications for a newly admitted resident in accordance with professional standards and its own admission policy. A cognitively intact resident with diagnoses including hypertension, hip fracture, stroke, depression, cognitive communication deficit, and atrial fibrillation was admitted with a physician order for doxazosin mesylate 2 mg, 0.5 tablet PO BID. The script sent to the pharmacy reflected this order, but the MAR was entered as doxazosin mesylate 1 mg, 0.5 tablet PO BID, and the medication was not available in the building. On the MAR for several scheduled doses over three days, staff documented the code “6” (see progress notes) instead of administering the medication. Progress notes documented that the medication was not given on the night of admission because staff were waiting for pharmacy delivery, but there was no documentation explaining why subsequent doses on the following days were not given. Blood pressure readings during this period showed varying values, and review of the emergency kit list confirmed that doxazosin was not stocked there. The resident’s family reported that the resident called to say she did not receive her medications on the day of admission or that night, and when the family member spoke with the charge nurse, the nurse stated the day nurse had not followed through with the orders. Staff interviews revealed that the usual admission process includes obtaining prior MARs, securing physician orders, entering them into the computer, and faxing them to the pharmacy, and that if medications are not available, staff may obtain an order to start later or use the emergency kit if immediate administration is needed. The DON stated that if the medication had not been delivered, staff should have initiated calls to obtain it as soon as possible and checked the emergency kit. The ADON/MDS Coordinator later identified that the script sent to the pharmacy did not match the MAR order and noted that staff should have documented in progress notes why the medication was not given. The facility’s admission policy requires that the attending physician provide medication orders needed for the immediate care of the resident prior to or at admission.
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