Failure to Notify Physician and Representative of Medication Given Outside Ordered Parameters
Penalty
Summary
The facility failed to notify the physician and resident representative when a resident received Hydralazine outside of the physician-ordered blood pressure parameters. The resident, who was cognitively intact with a BIMS score of 14, had an order for Hydralazine to be held if the systolic blood pressure (SBP) was less than 150. Despite this, the medication was administered multiple times when the resident's SBP was below the ordered threshold, as documented in the Medication Administration Record (MAR). In some instances, blood pressure readings were not recorded on the MAR at all. Interviews confirmed that the family member was concerned about the administration of blood pressure medication outside of prescribed parameters, and the Director of Nursing acknowledged that the physician should have been notified when the medication was given outside of parameters. Facility policy required staff to obtain and record vital signs, hold medications outside of parameters, and notify the physician in the event of a medication error, but these steps were not followed in this case.