Failure to Administer PRN Bumetanide per Physician Order Based on Weight Gain
Penalty
Summary
Surveyors identified a deficiency related to failure to ensure a resident was free from significant medication errors when PRN bumetanide was not administered as ordered. The resident had diagnoses including dementia, chronic kidney disease, localized swelling, and interstitial pulmonary disease, and had a Brief Interview for Mental Status score indicating moderate cognitive deficit. The physician’s order, effective since 12/08/2025, directed administration of bumetanide 1 mg by mouth daily as needed for weight gain of more than two pounds in one day or more than three pounds in five days. The resident’s care plan did not include a problem area related to medication administration. Weight records for the month showed multiple instances of weight gain that met the parameters for bumetanide administration. The vitals/weight report documented specific daily weights demonstrating that the resident met the criteria for bumetanide on several days. Based on these weights, the medication should have been administered on multiple dates, including 1/3, 1/6, 1/7, 1/9, 1/11, 1/16, and 1/22. However, review of the Medication Administration Record showed that on many days the medication entry was marked with initials in parentheses, which the Regional Clinical Director confirmed indicated the medication was not given. The Regional Clinical Director also confirmed that the medication should have been administered whenever the resident had the specified weight gain and that this did not occur on at least 1/6, 1/7, and 1/16, contrary to the physician’s order and the facility’s policy requiring physician orders to be followed or the physician and DON to be notified if not followed.
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