F0757

D

Failure to Ensure Physician Oversight and Adherence to Medication Parameters

Pleasantville, Ohio Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The deficiency involves failures in medication management and physician oversight, resulting in residents receiving unnecessary or improperly monitored drugs. One resident with dementia, muscle weakness, adult failure to thrive, and poly osteoarthritis was admitted with moderate cognitive impairment and required assistance with activities of daily living. After an emergency department visit, this resident was prescribed a lidocaine topical patch and tizanidine for pain and muscle spasms. These new medications were entered as verbal orders from an outside certified nurse practitioner but were never signed, and there was no documented communication with any facility provider about the new medications. Despite the lack of provider sign-off or documented oversight, nursing staff administered these medications along with multiple other antianxiety, muscle relaxant, and pain medications already ordered for the resident.

Over several days, the resident received Xanax, baclofen, hydroxyzine, tramadol, Tylenol, lidocaine patch, and tizanidine. Subsequently, the resident experienced a fall and was noted to be slower to respond, with slurred speech. The on-call physician was notified, and the resident was sent to the emergency department, where documentation indicated a diagnosis of polypharmacy with muscle relaxants held and mental status improvement. Review of the medical record confirmed that the emergency room orders from the earlier visit were never signed by the ordering nurse practitioner, there was no documentation of communication with any facility provider regarding the new medications, and no in-house provider visits were documented during that period. The regional nurse confirmed that no documentation could be provided to show provider awareness or oversight of the new medications.

A second resident with dementia, hypotension, anxiety disorder, mood disorder, major depressive disorder, and paraphilia had an active care plan for altered cardiovascular status related to hypotension, including medication as ordered by the physician. The physician ordered midodrine 15 mg three times daily with instructions to hold the medication if systolic blood pressure was greater than 110 mmHg. Review of multiple months of MARs showed that midodrine was repeatedly administered when the resident’s systolic blood pressure exceeded 110 mmHg at various morning, afternoon, and evening doses. The regional nurse verified that the resident had systolic blood pressure readings greater than 110 mmHg throughout the review period and that midodrine was not held as ordered. Facility policy required medications to be administered in a safe and timely manner and as prescribed, but the ordered parameters were not followed.

A third resident with end-stage renal disease on dialysis, type 2 diabetes, major depressive disorder, opioid dependence, anxiety disorder, and long-term antibiotic use had a care plan for hypertension that included providing antihypertensive medication as ordered, monitoring for side effects, monitoring blood pressure as clinically indicated, and reporting signs of malignant hypertension. The physician ordered clonidine 0.1 mg, three tablets by mouth twice daily, with instructions to hold the medication for systolic blood pressure above 110 mmHg and pulse above 60 bpm. Review of the MAR and vital signs over a one-month period showed that clonidine was scheduled for administration at 10:00 a.m. and 10:00 p.m., but there was no evidence that blood pressure was checked for the evening dose and no evidence that heart rate was obtained at any time during the review period. The regional nurse later verified that the parameters in the order were incorrect and that the medication should have been held for systolic blood pressure below 110 mmHg and pulse below 60 bpm. The facility’s medication administration policy required medications to be administered in accordance with orders, but the required monitoring parameters were not followed or correctly applied.