Failure to Follow Ordered Parameters for Antihypertensive and PRN Pain Medications
Penalty
Summary
The deficiency involves the facility’s failure to administer blood pressure and pain medications within ordered parameters for one resident. The resident was admitted with diagnoses including spinal stenosis, essential hypertension, alcohol dependence, and hyperlipidemia, and had no documented cognitive deficit on the admission MDS. Physician orders included Carvedilol 25 mg twice daily, Hydrochlorothiazide 25 mg daily, and Lisinopril 40 mg daily, all with parameters to hold the medications and notify the physician or NP if the systolic blood pressure (SBP) was less than 110 mmHg, and for Carvedilol also if the pulse was less than 60. Review of the MAR showed that on 01/05/26 all three antihypertensive medications were administered when the resident’s SBP was documented as 108 mmHg, and there was no corresponding documentation in the progress notes that the physician or NP had been notified or had given an order to administer the medications outside the established parameters. The resident also had an order for PRN Oxycodone 5 mg every four hours as needed for mild to moderate pain, defined as pain levels one to five. Review of the MAR revealed that Oxycodone was administered on 01/13/26 when the resident’s documented pain level was zero, indicating administration outside the ordered pain parameters. The DON confirmed in interview that blood pressure medications should not be given when vital signs fall outside ordered parameters unless the physician provides an order, and that PRN pain medications should only be administered within the ordered parameters or with documented physician authorization to deviate. Facility policy on Medication Administration required the nurse to check special instructions and contraindications, including vital signs and other assessments, before giving medications, and to document the reason for administering PRN medications in the MAR and resident chart. These requirements were not followed in this case, resulting in the cited noncompliance.
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