Medication Parameter Errors and Unauthorized Compression Device Use
Penalty
Summary
The deficiency involves failures to follow physician orders and to ensure appropriate orders were in place for treatments and medications. For one resident with dependence on renal dialysis and heart failure, a physician’s order dated 2/16/26 directed administration of midodrine 10 mg three times daily for hypotension, to be held if blood pressure was greater than 130/90. The February 2026 MAR showed midodrine was administered on multiple occasions when the systolic blood pressure exceeded 130 (including readings of 150/86, 146/59, and 141/78), and on one date the medication was not given when the blood pressure was 119/64, with a note stating the blood pressure was outside parameters. The DON stated the midodrine parameters came from hospital discharge orders, acknowledged the order was not clear, and indicated staff education was needed. Another resident with heart failure had a physician’s order dated 1/31/26 for midodrine 2.5 mg by mouth three times a day, to be held if systolic blood pressure was greater than 110. The February 2026 MAR indicated midodrine was administered several times when systolic blood pressure was above 110, including readings of 123/75, 136/74, 135/87, 129/72, and 117/63. A separate deficiency involved the use of compression leg wraps without a corresponding physician order. One resident with diabetes mellitus, a left tibia fracture, bilateral lower extremity impairment, and care plans for diuretic therapy related to edema and anticoagulant therapy for DVT prevention was observed with compression leg wraps and a connected machine in his room. Initially, the wraps were folded in a bag on the bed, and the resident reported not knowing who brought them or whether he or staff were supposed to apply them. On a later observation, the wraps were opened and connected to the machine on the bed. Record review showed no physician orders for the compression leg wraps. An RN stated she was unaware the wraps were on the bed and confirmed there was no order, and the DON stated the resident was supposed to wear the leg wraps for leg swelling and that the company must have dropped them off without notifying staff, adding that there should have been an order in the computer.
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