A resident’s midodrine was administered multiple times despite MAR-documented BPs above the prescriber’s hold parameter of SBP > 120. The RN stated a check mark means the med was given and was unsure why the resident’s midodrine was marked that way, while the DON confirmed the med should not have been administered when BP was outside parameters and that the MAR check mark indicates administration.
A resident on warfarin for a mechanical heart valve had critically elevated PT/INR values documented, yet nursing staff continued to administer warfarin, including during a period when the drug was ordered to be held. The MAR shows doses given on days when INRs were elevated, with no evidence that the physician was notified before administration. After a critically high INR, the provider ordered vitamin K and daily PT/INR labs for two days, but the ordered labs were not drawn as scheduled, and the next INR was not obtained until after the resident became nonresponsive and stopped eating. The DON later confirmed that the labs were missed and that there was no documentation of timely physician contact regarding the elevated INRs.
A facility failed to ensure medications were administered only within ordered parameters for three residents. One resident received Cozaar when HR was below the hold limit and there was no provider notification documented. Another resident had Amlodipine and Metoprolol documented as given when BP or HR were below ordered parameters, and staff said one entry was a documentation error. A third resident’s scheduled insulin was documented as given when blood sugar values were below the hold parameter, with staff describing the entries as missed documentation.
Unnecessary Medication Administration Outside Ordered Parameters: Two residents received medications outside ordered parameters. One resident was given metoprolol despite BP readings below or near the hold limits, and an LPN stated it was administered in error. Another resident received topical diclofenac as ordered on the MAR until the order was discontinued, with an LPN stating she applied the gel but could not recall the amount. The DON stated staff were expected to clarify unclear medication orders and follow physician parameters, and the MD said he reviewed the residents and found no adverse events.
Surveyors found that nurses failed to follow physician-ordered vital sign parameters for antihypertensive medications for two residents. One resident with multiple chronic conditions, including essential hypertension and mild cognitive impairment, received metoprolol doses despite heart rates below the ordered hold threshold. Another resident received hydralazine even when systolic blood pressures were outside the specified parameters. Nursing staff acknowledged administering these medications outside the prescribed limits, and the DON confirmed that facility policy requires medications to be given in accordance with physician orders and associated vital sign checks.
A resident with a prosthetic heart valve on warfarin therapy had significantly elevated INR values, yet nursing staff continued to administer warfarin without documented physician notification or guidance and in conflict with hold orders. PT/INR monitoring was ordered but not consistently completed as prescribed, including missed ordered labs on consecutive days, and there was no evidence of staff follow-up with the lab to ensure testing occurred. The resident subsequently exhibited lethargy, decreased responsiveness, and poor oral intake, leading to further evaluation and hospital transfer, and the DON later confirmed the lapses in lab monitoring and lack of documented provider contact.
A resident had an order for midodrine 5 mg three times daily with instructions to hold the dose if systolic BP exceeded a specified parameter. Review of the MAR showed 13 documented administrations of midodrine outside these ordered parameters. Two LPNs reported that they always check BP before giving parameter-based medications and believed the entries were documentation errors, while the DON stated that nursing staff are expected to follow physician orders, including specific parameters. The discrepancy between the physician order and the documented administrations resulted in a deficiency related to unnecessary drugs.
Medication Administered Outside Ordered Parameters: Two residents received meds outside physician-ordered hold parameters. One resident was given Midodrine despite BP readings above the ordered threshold, and another resident received Metoprolol multiple times when pulse was below the ordered hold limit. An RN and an LPN stated they were not aware of or did not recall the parameters, while the physicians expected staff to follow the orders.
PRN Psychotropic Medication Order Lacked Required End Date: A resident with generalized anxiety disorder and mild major depressive disorder had a PRN Alprazolam order for anxiety that was written with an indefinite end date. The MAR showed the medication was administered multiple times, and the DON stated the order should have had a 14-day end date rather than no end date.
Failure to Follow BP Medication Hold Parameters: The facility administered antihypertensive medications outside ordered SBP, DBP, and HR parameters for multiple residents. MARs showed metoprolol, lisinopril, losartan, and carvedilol were given when vital signs were below hold limits, and LPNs acknowledged they did not follow the physician orders. The DON stated that physician orders and medication parameters should be followed.
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