Failure to Follow Medication Parameters and Obtain Timely Admission Weights
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for medication administration and to obtain required admission weights for multiple residents. For one resident with hypotension, vitamin deficiency, acute kidney failure, and iron deficiency anemia, a care plan dated 3/19/26 identified potential for cardiovascular distress and included an intervention to administer medications as ordered. A physician’s order dated 3/11/26 directed administration of midodrine 5 mg four times daily, to be held for systolic blood pressure greater than 110. Review of the MAR from 3/11/26 through 3/25/26 showed midodrine was administered despite systolic blood pressures above the ordered hold parameter on several occasions, including readings of 167, 129, 112, 114, 111, and 127. The MAR also showed midodrine was held when it should have been given on multiple occasions when systolic blood pressure was at or below 110, with readings ranging from 100 to 110. The DON and an LPN confirmed during interviews that medications should not be administered or held outside of ordered parameters and that the MAR would reflect when medications were not given and the reason. The deficiency also includes failure to obtain admission weights as ordered or per facility guidelines for two residents. For one resident with diastolic congestive heart failure, dementia, type 2 diabetes mellitus, and anxiety disorder, a physician’s admission order dated 7/31/25 required a one-time weight, but no admission weight was found in the clinical record, and the DON stated the first weight was not obtained until 8/5/25. For another resident with cellulitis of the right lower limb, pulmonary fibrosis, dementia, diabetes mellitus, and hypertension, the resident was admitted on a specified date, but the admission weight was not obtained until three days later. Staff interviews revealed inconsistent understanding of when admission weights should be obtained: the Clinical Support Nurse stated the policy did not specify timing, while an LPN, another LPN, and a QMA each indicated admission weights should be obtained at admission, by the end of the admission shift, or within 24 hours. The facility’s Medication Administration General Guidelines policy stated medications are to be administered as prescribed, and the Guidelines for Weight Tracking policy stated residents will have their weight taken and recorded upon admission to establish a baseline.
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