Failure to Hold Diuretic Medication per Blood Pressure Parameters
Penalty
Summary
Facility staff failed to ensure that a resident was free from significant medication errors by not adhering to a physician's order regarding the administration of spironolactone, a diuretic prescribed for congestive heart failure. The physician's order specified that the medication should be held if the resident's systolic blood pressure (SBP) was less than 120 mmHg. Despite this, the medication administration record (MAR) showed that spironolactone was given on multiple occasions when the resident's SBP was below the specified threshold. The resident involved had a history of acute on chronic systolic heart failure, pulmonary hypertension, and essential hypertension, and was assessed as having moderate cognitive impairment. The care plan directed staff to administer medications as ordered, and the facility's policy required verification of vital signs prior to medication administration when necessary. However, nursing staff administered the medication without consistently checking or adhering to the SBP parameter outlined in the order. Interviews with nursing staff revealed a lack of awareness or attention to the hold parameter in the physician's order. One nurse stated she did not see the order to hold the medication, while another acknowledged administering the medication despite the low SBP, relying on subsequent blood pressure readings and familiarity with the resident. Facility leadership, including the DON and Director of Operations, confirmed the expectation that staff follow physician orders regarding vital sign parameters for medication administration.