Failure to Follow Physician Orders and Schedules Resulting in Significant Medication Errors
Penalty
Summary
The deficiency involves the facility’s failure to prevent significant medication errors for two residents by not following physician orders and established medication administration schedules. One resident with epilepsy, morbid obesity, contractures, anxiety, major depressive disorder, and arthritis had orders for carbamazepine extended-release and losartan potassium, with instructions to hold losartan only if the systolic blood pressure was less than 100. On the survey date, an RN obtained a blood pressure of 107/60 and, after the resident complained of nausea, administered an antinausea medication and stated she would return to give the scheduled morning medications. Later, when asked, the RN acknowledged she had not yet given the morning medications, and the MAR showed that she held the losartan despite the blood pressure not meeting the ordered parameter to hold the medication. Another resident with polycythemia vera, osteoarthritis, dysphagia, hypertension, weakness, cognitive communication deficit, atrial fibrillation, hypothyroidism, heart failure, dementia, major depressive disorder, and a history of falls had orders for hydroxyurea 500 mg (two capsules daily at 9:00 AM), metoprolol 25 mg (½ tablet at 9:00 AM and 9:00 PM), and diltiazem 30 mg (three times daily at 9:00 AM, 1:00 PM, and 8:00 PM). On the survey date, the same RN administered these medications more than one hour after the scheduled time, gave only one capsule of hydroxyurea instead of the ordered two, held the metoprolol despite no physician-ordered parameters to do so, and administered diltiazem over an hour late. A regional nurse consultant stated that medications should be given within one hour before or after the scheduled time, that late medications should be reported to the physician for possible new orders, and that medications should only be held according to physician parameters. The facility’s policy required medications to be administered according to established schedules, and there was no facility policy specifically addressing significant medications.
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