Ongoing Administration of Metolazone Outside Ordered BP Parameters Despite Pharmacy Reviews
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a licensed pharmacist’s monthly drug regimen review and subsequent nursing actions prevented ongoing administration of a diuretic medication outside ordered parameters for one resident. The resident was admitted with diagnoses including heart failure, hypertension, and kidney disease and had a physician’s order for Metolazone 5 mg to be given orally on Mondays, Wednesdays, and Fridays for edema, with instructions to hold the medication if the systolic blood pressure was less than 110 or the diastolic blood pressure was less than 60. Review of the September Medication Administration Record (MAR) showed that Metolazone was administered multiple times by one nurse when the resident’s blood pressure readings were below the ordered parameters, including systolic readings under 110 and diastolic readings under 60. In October and November, the Consultant Pharmacist identified that Metolazone had been administered outside the ordered blood pressure parameters and documented this in monthly medication regimen review reports sent to the DON. The October review noted that the resident had received Metolazone outside parameters on several occasions in September and October, and the November review again informed the DON that the resident continued to receive Metolazone outside the ordered parameters. On both reports, the Unit Manager documented that nursing staff had been educated, but did not specify whether the nurse who administered the medication in error received this education or what specific education was provided. Despite these pharmacist reports, MARs for October and November showed that the same nurse continued to administer Metolazone on multiple dates when the resident’s blood pressure readings were below the ordered hold parameters. In December and January, the Consultant Pharmacist’s monthly medication regimen reviews did not include any recommendations regarding the resident’s Metolazone, even though the MARs for those months showed that the same nurse continued to administer the medication on numerous dates when the resident’s blood pressure readings remained below the ordered parameters. The Consultant Pharmacist later stated that she did not address Metolazone in those months and that this was missed, and she typically did not go back to review prior recommendations. The DON stated that she and the Unit Manager shared responsibility for reviewing and acting on the pharmacy reports and that the Metolazone issue was not reviewed in December or January to ensure the medication was being held per parameters. The nurse who administered the medication stated she was new, misunderstood the hold parameters as applying only if both systolic and diastolic pressures were below 110/60, and was not aware of the medication error until it was brought to her attention during the survey, despite being consistently assigned to the resident and administering Metolazone in this manner since September. This sequence of events shows that the facility did not act effectively on the Consultant Pharmacist’s October and November findings and that the Consultant Pharmacist did not continue to identify and address the ongoing issue in December and January, resulting in the resident continuing to receive Metolazone outside the physician-ordered blood pressure parameters over multiple months.
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