Failure to Hold Blood Pressure Medications per Physician Orders
Penalty
Summary
The facility failed to ensure that blood pressure medications were held according to physician-ordered parameters for two residents. For one resident with multiple diagnoses including traumatic brain injury, dementia, diabetes, and hypertension, physician orders specified that certain antihypertensive medications should be withheld if the systolic blood pressure or heart rate fell below set thresholds. Despite these orders, medication administration records showed that the resident received losartan, amlodipine, and Coreg on multiple occasions when the heart rate was below the specified parameters. Observation confirmed that a Certified Medication Aide administered these medications without recognizing the need to hold them due to a low heart rate. Another resident with diagnoses including heart failure, anxiety, and diabetes had a physician order for metoprolol to be held if the systolic blood pressure was below a certain level or if the pulse was under a set rate. Medication administration records indicated that this resident received metoprolol on several occasions when the systolic blood pressure was below the ordered threshold. Staff interviews revealed that Certified Medication Aides were expected to notify licensed nurses when vital signs were out of range, but this process was not consistently followed. The facility's own medication therapy policy required that medication regimens be consistent with physician orders and supported by appropriate care processes. However, the failure to adhere to physician-ordered parameters for holding medications resulted in the administration of unnecessary drugs, as defined by the facility's policy and federal regulations.