Failure to Administer Ordered Medications and Monitor Blood Pressure as Prescribed
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services and monitoring to meet the needs of a cognitively intact resident with multiple serious medical conditions. The resident was admitted following a hospitalization for a left cerebellar intracranial hemorrhage and had diagnoses including intracranial hemorrhage, dysphagia, morbid obesity, atrial fibrillation, heart disease, TIA, Parkinson’s disease, and cognitive impairment. The resident’s admission MDS documented use of a walker and manual wheelchair, substantial/maximal assistance needs for ADLs, and dependence on staff for toileting hygiene, with a BIMS score of 15 indicating intact cognition. The facility’s policy on Medication Orders required that current orders be maintained in the clinical record, with clear specifications for type, route, dosage, frequency, and strength, and that PRN orders include the reason for administration. Surveyors reviewed the resident’s physician orders, which included multiple scheduled medications for hypertension, hyperlipidemia, insomnia, constipation, depression, Parkinson’s disease, and atrial fibrillation, as well as orders for BP and heart rate checks three times daily and PRN Hydralazine for elevated systolic blood pressure. Despite these orders, the Medication Administration Record showed numerous missed scheduled medications on multiple dates in January and February, including Amlodipine, Atorvastatin, Melatonin, Polyethylene Glycol, Trazodone, Amantadine, Carvedilol, Eliquis, Lisinopril, Sennosides, and Hydralazine. The resident reported not always receiving scheduled medications and specifically not receiving medications on the day of admission. The resident also stated that some scheduled blood pressure medications had not been received and expressed concern about frequent missed medications, though the resident could not provide exact dates and times. Surveyors further identified failures in blood pressure monitoring and PRN medication administration. The BP log and MAR showed multiple missed BP readings across many days in January and February, despite an order to check BP and heart rate three times daily. On at least one occasion, the resident had a documented systolic BP greater than 175 without PRN Hydralazine being administered as ordered. Conversely, Hydralazine was administered several times when the systolic BP was less than 130, during a period when the order specified it should be held if SBP was below 130. Interviews with the NP revealed that she relied on BP readings recorded via a BP machine linked to the resident’s cell phone, but the resident stated they could not perform BP checks independently and required staff assistance, with the BP machine observed out of reach at the bedside. Interviews with an LPN and the ADON confirmed that missed medications could not be identified by looking at bubble packs and that staff were expected to document refusals or unavailability in the MAR or progress notes. Review of the MAR and BP logs with the ADON confirmed multiple missed medication administrations, missed BP checks, and lack of PRN Hydralazine use when indicated, with no explanation provided by facility leadership.
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