Medication Administration Error Due to Failure to Hold Antihypertensives for Low Heart Rate
Penalty
Summary
A resident with multiple diagnoses, including traumatic brain injury, dementia, depression, diabetes mellitus type two, and hypertension, was dependent on staff for all activities of daily living and received several daily medications, including diuretics, antidepressants, and insulin. The resident's care plan and physician's orders required staff to monitor blood pressure and heart rate, and to hold specific blood pressure medications if the systolic blood pressure was below 110 mmHg or the heart rate was below 60 or 65 beats per minute, depending on the medication. On the day of the incident, a Certified Medication Aide (CMA) measured the resident's heart rate at 55 beats per minute but proceeded to administer all prescribed blood pressure medications, failing to recognize that the heart rate was below the physician-ordered parameters for holding the medication. The CMA stated that they were only aware of the blood pressure parameter and not the heart rate requirement. The Licensed Nurse later confirmed that CMAs were expected to notify a nurse when vital signs were out of range, as some orders required physician notification. The administrative nurse also stated that staff were expected to follow physician orders and hold medications when vital signs were out of parameters. The facility did not provide a policy for medication errors when requested.