DENVER, CO- BRIARWOOD HEALTH CARE CENTER

Based on record review and staff interviews, the facility failed to ensure one (#36) of three residents, received medication management treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan for 26 sample residents reviewed.

Specifically, the facility failed to follow current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #36 ‘ s blood pressure and heart rate were outside of parameter ranges to give the medication.

Resident #36 was interviewed on 3/15/22 at 10:35 a.m. She said she did not feel light headed or dizzy laying in bed however felt that way with transfers from the bed to the wheelchair each day. She said felt light headedness and dizziness with every transfer that occurred at about 12:30 p.m. when she got up each day.

The January 2022 medication administration record (MAR) revealed [MEDICATION(S)] [MEDICATION(S)] was administered in these instances when the heart rate was out of the parameters of the physician order

The February 2022 medication administration record (MAR) revealed [MEDICATION(S)] [MEDICATION(S)] was administered in these instances when the systolic blood pressure was out of the parameters of the physician order

The March 2022 medication administration record (MAR) revealed [MEDICATION(S)] [MEDICATION(S)] was administered in these instances when the systolic blood pressure was out of the parameters of the physician order

LPN #1 was interviewed on 3/15/22 at 10:54 a.m. She said the process for administering a medication such as [MEDICATION(S)] [MEDICATION(S)] was to look at the orders first and then check the blood pressure and heart rate parameters and to hold the medication if out of the parameter ranges. LPN #1 said if medication were administered when out of parameter range the blood pressure would drop even more, causing the resident to feel tired, weak, dizzy, or light headed. LPN #1 said if the heart rate was already low and the medication was given the resident could pass out or have [CONDITION(S)] (slow heart rate). LPN #1 viewed Resident #36 ‘ s MAR and vitals on 3/12/22 and said the blood pressure and heart rate were low and the medication should have been held.

The DON was interviewed on 3/15/22 at 11:20 a.m. She said the process for administering a medication such as [MEDICATION(S)] [MEDICATION(S)] was to check the doctors orders and parameters and hold if needed in order to stay within the parameters. The DON said it was important in order to keep the resident from bottoming out with symptoms of increased lethargy and dizziness when sitting up. The DON said the nurse should be checking the blood pressure and heart rate prior to administration. The DON viewed Resident #36 ‘ s MAR and vitals on 3/12/22 and acknowledged that the morning and bedtime doses had been administered although the blood pressure and heart rate vitals were out of range of the physician orders. The DON said the medication should have been held.