Failure to Follow Medication Administration Standards and Verify Appropriate Routes
Penalty
Summary
The facility failed to ensure residents received treatment and care in accordance with professional standards of practice and their comprehensive person-centered care plans for two residents. For one resident with hypertension and acute pancreatitis, physician orders directed that lisinopril 10 mg by mouth daily be held for systolic blood pressure less than 100, and metoprolol succinate extended-release 25 mg by mouth daily be held for heart rate less than 55 or systolic blood pressure less than 100. On the morning of 3/19/26, an LPN administered both metoprolol and lisinopril without checking the resident’s blood pressure and heart rate at that time. The LPN later stated that vital signs had been taken earlier by a CNA and were 132/78, and acknowledged she probably should have checked the vital signs prior to administering the anti-hypertensive medications. The facility also failed to ensure correct medication orders and routes of administration for another resident with diabetes, kidney disease, and an ileostomy. This resident’s record contained active orders for Dulcolax (bisacodyl) 10 mg suppository to be inserted rectally as needed for constipation and a Fleet enema to be inserted rectally as needed for constipation, both ordered on 5/8/23. Given the resident’s ileostomy, the Staff Development Coordinator confirmed that the resident should not have any orders for medications to be given rectally and that the routes on the bisacodyl and enema orders were wrong, and further stated the resident should not even have those orders. These issues were identified through observation, record review, policy review, and staff interviews.
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