Failure to Follow Physician's Orders for Blood Pressure Medication
Penalty
No penalty information released
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Summary
Staff failed to follow a physician's order for a resident with end stage renal disease and heart failure, which required administration of midodrine three times daily for hypotension, with the specific instruction not to administer the medication if the resident's systolic blood pressure (SBP) exceeded 130 mm/Hg. Clinical record review showed that the medication was given on three separate occasions when the resident's SBP was above the prescribed threshold. The Director of Nursing confirmed that the medication was administered outside of the established parameters for this resident.