Failure to Follow Physician Orders for Blood Pressure Medications
Penalty
Summary
The facility failed to ensure that physician's orders were followed for two residents, resulting in care and treatment not being provided in accordance with professional standards of practice. For one resident with a history of congestive heart failure and hypertension, physician's orders required Hydralazine to be held if the systolic blood pressure was less than 120 mmHg. However, review of the Medication Administration Record (MAR) showed that the medication was administered on multiple occasions when the resident's systolic blood pressure was below the specified threshold, with no documentation that the medication was held as ordered. Similarly, another resident with hypertension and dementia had a physician's order for metoprolol tartrate to be held if the systolic blood pressure was less than 130 mmHg or if the heart rate was less than 60 beats per minute. The MAR indicated that the medication was not held on several occasions when the resident's systolic blood pressure was below the ordered threshold, and there was no documentation to show compliance with the physician's order. These findings were confirmed in an interview with Clinical Compliance staff.