Failure to Hold Blood Pressure Medication per Physician Order
Penalty
Summary
A deficiency was identified when the facility failed to administer blood pressure medication in accordance with a physician's order for one resident. The resident, who had diagnoses including sepsis, congestive heart failure, and endocarditis, had an active order for hydralazine 25 mg by mouth twice daily, with instructions to hold the medication if the systolic blood pressure (SBP) was less than 140. Despite this order, the Medication Administration Record (MAR) showed that hydralazine was administered multiple times when the resident's SBP was below 140, with recorded SBP values ranging from 106 to 138 at the time of administration. Interviews with the Director of Nursing (DON) confirmed that the medication was given contrary to the physician's order on several occasions, and a review of the electronic medical record did not reveal any documentation that the medication had been appropriately held on those dates. The facility's policy requires medications to be administered according to written physician orders, but this was not followed in the case of this resident.
Plan Of Correction
F tag 658 Services Provided Meet Professional Standards SS=D 1. Resident R69 no longer resides at the facility. On 4/24, the DON notified the Nurse Practitioner of the findings. Patients' charts and vitals were reviewed. The patient was assessed and showed no signs of distress. Education was initiated. Resident discharged home with her spouse on 5/4/2025. 2. Residents residing in the facility receiving blood pressure medications are at risk of being affected by this deficient practice. Residents receiving BP meds with parameters were reviewed by the DON to ensure that medications were held if the BP was not within parameters. Any concerns were addressed. 3. The QAPI Committee reviewed the Medication Administration Policy and deemed it appropriate. Nursing staff were re-educated by the DON/Designee on the policies and procedures related to Medication Administration specific to medications with parameters. Staff who have not been educated by the Date of Compliance will be re-educated prior to returning to work. 4. The DON/Designee will review 5 residents weekly times four to ensure that physician orders are followed regarding medication parameters then monthly x 3 months. The results of these audits will be forwarded to the QA Committee for further guidance and direction. The NHA is responsible for continued compliance.