Failure to Follow Medication Administration Parameters for Midodrine
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not adhering to the prescribed parameters for administering Midodrine, a medication used to treat hypotension. The resident had active orders specifying that Midodrine should be held if the systolic blood pressure (BP) was greater than 120 mm Hg or the diastolic BP was greater than 80 mm Hg. However, medication administration records revealed that the medication was frequently given when the resident's BP readings were above the specified parameters and held when the readings were below, contrary to the physician's orders. Multiple medication aides and nurses administered Midodrine in error, either by not noticing the parameters, misunderstanding the order, or documenting incorrectly. Several staff members admitted during interviews that they were aware of the parameters but failed to follow them due to oversight, misinterpretation, or the hectic nature of their assignments. Some staff also reported being unfamiliar with the specific requirements of the order or being distracted by other duties, leading to the administration of the medication outside the prescribed parameters. The errors were not identified or reported by the facility's leadership, including the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, and the Administrator, all of whom stated they were unaware of the medication errors until notified during the survey. The Consultant Pharmacist noted the errors but did not report the full extent to the facility, believing the issue was not clinically significant and that staff education was already underway. The Unit Manager also did not receive pharmacy recommendations regarding the errors. The Medical Director confirmed that she was not notified of the errors and expected medications to be administered according to the ordered parameters. Despite the significant number of errors, the resident did not experience a significant outcome.