Failure to Follow Professional Standards in BP Monitoring and Medication Administration
Penalty
Summary
The deficiency involves failures to follow accepted professional standards of clinical practice during care and medication administration for multiple residents. For a resident with end stage renal disease and an AV fistula in the left forearm for hemodialysis, the care plan specified that blood pressures should not be taken on the left arm. Despite this, the resident’s vital sign records showed 18 blood pressure readings documented as taken on the left arm over a 90‑day period. The DON later confirmed the record showed blood pressures taken on the left arm and suggested the person measuring the blood pressure may have documented incorrectly, while also stating there had been no adverse outcomes and that the resident was aware blood pressures should not be taken on that arm. Additional deficiencies were identified in insulin administration and oral medication administration. For a resident with diabetes, physician orders required Novolog (insulin aspart) three times daily and Toujeo (insulin glargine) twice daily. During observation, an RN sanitized and re‑needled both insulin pens, dialed each pen directly to the ordered dose, and administered the injections without priming either pen, contrary to the manufacturers’ Instructions for Use that require priming to ensure proper dosing. For another resident with heart failure, dysphagia, and sleep apnea who was ordered potassium chloride 20 mEq twice daily, an LPN dissolved the potassium chloride in a small amount of water, mixed it with pudding, and administered it. When the resident declined water afterward, the LPN did not provide education about the importance of drinking a full glass of water after taking potassium chloride, despite reference material indicating it should be taken with food or just after a meal and followed with a full glass of water to reduce stomach irritation.
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