Failure to Administer Blood Pressure Medication as Ordered
Penalty
Summary
The facility failed to ensure the proper administration of blood pressure medication, Clonidine, for a resident as per the physician's order. During a medication pass observation, it was noted that the resident had a blood pressure of 197/96, which required the administration of Clonidine and notification to the physician as per the order. However, the previous blood pressure reading of 196/88 at 5:00 AM was not reported to the physician, and there was no documentation of this notification in the progress notes. The resident's Medication Administration Record (MAR) showed only two previous administrations of the PRN Clonidine, despite multiple instances of elevated blood pressure readings that met the criteria for administration. The resident, who was admitted with diagnoses including stroke, heart disease, chronic kidney disease, and malnutrition, had a history of moderately impaired cognition and required assistance with daily activities. The facility's failure to administer the medication as needed and to notify the physician of elevated blood pressure readings was confirmed by the Unit Manager, who acknowledged that the expectation was to follow the physician's orders and report out-of-parameter blood pressures. The resident's electronic medical record documented ten or more instances of systolic blood pressures greater than 160 since the order was initiated, indicating a pattern of non-compliance with the prescribed medication regimen.
Plan Of Correction
Element 1 It is the practice of the facility that Residents are Free of Significant Medication Errors and to ensure the PRN blood pressure medication (Clonidine) is administered as needed per physician orders. Element 2 Residents that receive PRN Clonidine have the potential to be affected by this cited practice. R73 was seen and evaluated at bedside on 4/11/25 & 4/14/25 by physician for hypertension and refusal of medication. Element 3 The Interdisciplinary Team reviewed the policy and procedure on Medication Administration and deemed it to be appropriate. Nursing was educated on PRN blood pressure medication administration and to recheck blood pressure within 1 hour. If SBP is greater than 160 to call the physician. Element 4 UM/Designee will audit residents who have PRN blood pressure medication to ensure they are given appropriately weekly x4 then monthly x3. Results of audits will be taken through QA for further review and recommendations. Element 5 The Administrator will be responsible for sustaining compliance.