Failure to Follow Blood Pressure Parameters for Antihypertensive Medication Administration
Penalty
Summary
A deficiency occurred when nursing staff failed to follow professional standards of nursing practice for medication administration for one resident. The resident, who was prescribed Apresoline for hypertension with specific physician orders to hold the medication if systolic blood pressure (SBP) was less than 130, reported that a registered nurse did not listen to her concerns about low blood pressure and administered the medication despite her warning. Documentation review showed that the resident's blood pressure was 112/56 earlier that day, and there was no record of a blood pressure reading prior to the evening dose when the medication was given. The medication administration record indicated the medication was given in the evening, and there was no documentation of a blood pressure reading or assessment for dizziness at that time. Interviews with staff confirmed that the resident was knowledgeable about her medications and often reminded nurses when her blood pressure was too low for antihypertensive administration. Staff also reported that the medication was frequently held due to low SBP, and dizziness was a known side effect for this resident when her blood pressure was low. The Director of Nursing stated that nurses were expected to verify and document blood pressure readings in accordance with physician orders before administering such medications, but this was not done in this instance. The failure to obtain and document the required assessment prior to medication administration led to the deficiency.
Plan Of Correction
The nurse of the affected resident was provided one-to-one education about the parameters. Nurses will continue to be educated on expectations related to parameters and medication administration. All residents have potential to be affected. Education will be provided to all nurses regarding medication administration expectations for orders with specified parameters. Medication administration expectations related to parameters will be included in new hire orientation. Medication administration policies were reviewed and no necessary updates were identified. The Clinical Oversight Committee will complete five weekly audits of medications with ordered parameters to ensure compliance for the next 12 weeks. The Executive Director is responsible for compliance.