State Findings:
Based on record review, interviews, and review of the facility policy titled Pharmacy Services Medication Administration General, the facility failed to follow Physician’s Orders related to a blood pressure medication for one of five residents ((R) R#44) reviewed for unnecessary medication.
Findings include:
Review of policy titled Pharmacy Services Medication Administration General (dated 2019) revealed medications are to be administered as prescribed, in accordance with good nursing principles.
Review of the medical record revealed R#44 admitted to facility on 10/25/22 and had an admitting diagnosis that included unspecified, essential (primary) hypertension.
R#44 also had a Physician Order for carvedilol 25 milligrams (mg) tablet (CARVEDILOL) 1 tablet by mouth 2 times per day, hold if Systolic BP (blood pressure) Less than 140, hold if Diastolic BP Less than 90 with a start date of 11/25/22.
Review of the electronic medication administration record (EMAR) for November 2022 revealed the medication carvedilol was administered with the following blood pressure at 9 a.m. on 11/25 – 138/72; 11/26 – 138/74; 11/27 -120/70; and 11/30 – 132/62.
Review of the EMAR for December 2022 revealed the medication carvedilol was administered with the following blood pressure at 9 a.m. on 12/1 -138/70; 12/5 – 144/68; 12/6 – 140/68; 12/9 -140/68; 12/10 – 138/72; 12/11 – 138/78; 12/12 – 159/75; 12/14 – 140/68; and 12/15 -128/70.
Review of the EMAR for November 2022 and December 2022 revealed the medication carvedilol was administered with the following blood pressure at 8 p.m. on 12/1 – 157/77; 12/2 – 166/88; 12/3 -136/69; 12/4 – 145/77; 12/5 – 148/84; 12/6 – 148/75; 12/7 – 134/65; 12/8 – 149/67; 12/9 -122/76; 12/10 – 146/86; 12/11 – 148/80; 12/12 – 156/76; 12/13 – 136/72; 12/14 – 142/86; 12/15 – 146/82; 11/25 – 96/56; 11/26 – 128/86; 11/27 – 148/78; and 11/29 – 133/72.
Consultant Pharmacist’s Medication Regiment Review Recommendations Pending a Final Response dated 12/16/22 revealed Pharmacy recommended Carvedilol should be given with food to minimize the risk of orthostatic hypotension. Please consider changing administration times to coincide with meals 9 am and 6pm.
During an interview on 12/18/22 at 10:55 a.m. with Licensed Practical Nurse (LPN) AA confirmed that there have been trainings provided to staff related to monitoring the parameters of blood pressure for residents. LPN AA reviewed the EMAR for December 2022 and confirmed dates in which carvedilol should have been held but was administered outside of the parameters of the order.
During an interview with on 12/18/22 at 11:16 a.m. with the Director of Nursing (DON) and Resident Care Coordinator (RCC) HH, the DON reported that she was not aware of the medication being administered outside of the parameters of the order until she received info from the pharmacist on 12/16/22. DON confirmed that medication for R#44 was not being administered as ordered.
The pharmacist was called, and a message was left but there was no response.
A post survey interview with R#44’s Physician was conducted on 12/18/22 at 3:16 p.m. The Physician expressed that the expectation is that medications are administered as ordered and after review of what was entered on the EMAR, he confirmed that the medication should have been held if it was outside of the parameters listed on the order.
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