Failure to Administer Ordered Medications Despite Availability
Penalty
Summary
The deficiency involves the facility’s failure to administer medications in accordance with physician orders for multiple residents, despite medications being available on site. One resident with type 2 diabetes mellitus with hyperglycemia, chronic kidney disease, hypertension, and hypokalemia was admitted from the hospital with a history of chronically elevated systolic blood pressure up to the 190s and severe cognitive impairment, dependent on staff for activities of daily living. Hospital discharge orders and subsequent physician orders included multiple antihypertensives, insulin aspart on a low-dose sliding scale, and several other medications. On the evening of admission, the resident did not receive ordered doses of amlodipine, hydralazine, and trazodone, and blood sugar was not monitored and insulin was not administered. The following day, the resident did not receive hydrochlorothiazide, lisinopril, morning doses of amlodipine and hydralazine, atenolol, fenofibrate, pantoprazole sodium, pregabalin, and sertraline, even though the facility’s Medication Inventory on Hand report showed these medications were available. The DON confirmed the medications were not administered per physician orders and that the nurse should have used medications on hand and clarified which medications the resident had been receiving prior to leaving the hospital. Another resident with Parkinson’s disease with dyskinesia, hypertension, atrial fibrillation, and gait and mobility abnormalities, and with severe cognitive impairment, was admitted with hospital orders for carbidopa-levodopa 25/100 mg three times daily. The physician orders at the facility also reflected carbidopa-levodopa 25/100 mg three times daily. Review of the MAR showed that the resident did not receive the evening and bedtime doses of carbidopa-levodopa on one day, and did not receive the bedtime dose the following day. The Medication Inventory on Hand report indicated that carbidopa-levodopa was available for administration, and nursing notes contained no documentation that the resident refused the medication. The DON verified that the medication was not administered as ordered, despite being available in the facility. A third resident with acute systolic heart failure, acute pulmonary edema, cardiomegaly, and hypertension, and with intact cognition, was admitted with hospital discharge orders for carvedilol 6.25 mg twice daily. The facility’s physician order mirrored this, specifying carvedilol 6.25 mg twice daily for hypertension, to be held only if systolic blood pressure was less than 100 or pulse was less than 60 beats per minute. On the evening of admission, the resident’s vital signs showed a blood pressure of 116/59 and heart rate of 84, which did not meet the hold parameters. However, the MAR indicated that the evening dose of carvedilol was not administered, and nursing notes did not document any refusal. The Medication Inventory on Hand report showed carvedilol was available, and the DON confirmed that the medication was not administered per physician orders. Facility policies required medications to be administered according to written physician orders and allowed use of on-hand medication supply when pharmacy medications were not yet delivered, but these procedures were not followed in the cited instances.
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