Failure to Implement Care Plan for Midodrine Administration
Penalty
Summary
Facility staff failed to implement the comprehensive, person-centered care plan for one of six sampled residents, Resident #5, related to the administration of the medication Midodrine for hypotension associated with end stage renal disease (ESRD). The comprehensive care plan dated 11/3/2025 identified a focus of hypotension related to ESRD and included interventions to give medications as ordered and to monitor vital signs as ordered and as clinically indicated. Surveyors determined that staff did not follow the care-planned intervention to administer Midodrine per the physician’s orders. In an interview, LPN #4 stated that the care plan is intended to guide staff on how to care for residents and their individual needs. The facility’s written policy on comprehensive, person-centered care plans states that a comprehensive care plan with measurable objectives and timetables to meet residents’ physical, psychosocial, and functional needs is to be developed and implemented for each resident. Administrative staff, including the administrator, director of nursing, and regional director of operations, were informed of these findings during the survey, and no additional information was provided by the facility prior to survey exit.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.