Failure to Follow Physician's Order for Medication Administration Based on Blood Pressure Parameters
Penalty
Summary
A deficiency occurred when a licensed nurse failed to follow a physician's order regarding the administration of Furosemide for a resident with localized edema and pulmonary hypertension. The physician's order specified that Furosemide should be held if the resident's systolic blood pressure (SBP) was less than 110. Despite this, the medication was administered on a day when the resident's blood pressure was recorded as 98/68, which was below the prescribed threshold. During interviews and record reviews, the nurse stated that a verbal order had been given by the physician to continue the medication despite the low SBP, but there was no documentation in the resident's medical record or progress notes to support this claim. The Director of Nursing confirmed that there was no documentation authorizing the administration of Furosemide outside the original parameters. Facility policy required that medications be administered as prescribed and that vital signs be checked and documented when administration is dependent on such parameters, which was not followed in this instance.