Failure to Adhere to Blood Pressure Parameters for Medication Administration
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary medications by not adhering to physician-prescribed blood pressure parameters for three medications: amlodipine, spironolactone, and ethacrynic acid. The physician’s orders specified that amlodipine should be held if the systolic blood pressure was less than 115 mmHg or the heart rate was less than 56 bpm, and that both diuretics should be held if the systolic blood pressure was less than 110 mmHg or the heart rate was less than 60 bpm. Despite these parameters, the resident was administered amlodipine when their systolic blood pressure was 113 mmHg and both diuretics when their systolic blood pressure was 104 mmHg, as documented in the Medication Administration Records (MAR) for January and March. The resident had a history of hypertension and congestive heart failure and was determined to have the capacity to understand and make decisions. During interviews, the LVN confirmed that reminders regarding medication parameters were present on the MAR prior to administration, and both the DON and Administrator acknowledged the findings. The facility’s policy required medications to be administered in accordance with prescribed orders, but this was not followed in the instances identified.