Failure to Hold Medication per Physician-Ordered Blood Pressure Parameters
Penalty
Summary
A deficiency was identified when a resident received the medication Midodrine HCl outside of the physician-ordered parameters. The resident had an order for Midodrine HCl 5 mg by mouth three times daily for hypotension, with instructions to hold the medication if the systolic blood pressure (SBP) was greater than 120 mmHg. Despite this, the medication administration record (MAR) showed that the resident received Midodrine on multiple occasions when the SBP exceeded 120 mmHg, specifically on five occasions in March and eight occasions in April, as well as once in May. During an interview and record review, an LVN confirmed that the medication should not have been administered when the SBP was above the ordered threshold, acknowledging that the medication was given inappropriately on 14 separate incidents. The facility's medication administration policy required staff to obtain and record vital signs and to hold medications when vital signs were outside the physician's prescribed parameters, which was not followed in these instances.