Failure to Administer Antihypertensive Medications Leads to Hospitalizations
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, resulting in the resident not receiving prescribed blood pressure medications on multiple occasions. The resident, who had a diagnosis of hypertensive encephalopathy and was moderately cognitively intact, had physician orders for several antihypertensive medications, including Carvedilol, Isosorbide Mononitrate, Lisinopril, and later Hydralazine. On at least two documented occasions, the resident did not receive these medications as ordered, with the electronic medication administration record (MAR) showing missed doses and a lack of blood pressure recordings. Following these missed doses, the resident experienced hypertensive emergencies that required hospitalization. On one occasion, the resident was found on the floor complaining of pain, and his blood pressure was significantly elevated upon hospital admission. On another occasion, after missed medication doses and absent blood pressure documentation, the resident developed chest pain and was again hospitalized for a hypertensive emergency. Interviews with facility staff revealed that there was no policy provided regarding blood pressure parameters and following physician orders, and the DON stated that staff should use nursing judgment and follow physician orders.