Failure to Follow Hold Parameters for Antihypertensive Medication
Penalty
Summary
Licensed nursing staff failed to administer hydralazine according to the physician-ordered hold parameters for a resident with a history of hemiplegia, hemiparesis, and essential hypertension. The resident was cognitively impaired and dependent on staff for all activities of daily living. The medication order specified that hydralazine should be held if the systolic blood pressure was less than 110 mm Hg or the diastolic blood pressure was less than 60 mm Hg. Despite these clear instructions, the medication was administered 24 times over a period of approximately five weeks when the resident's blood pressure readings met the criteria for holding the medication. The MAR and interviews confirmed that the licensed nurse was responsible for following the hold parameters but did not do so, resulting in the resident receiving hydralazine outside of the prescribed safety limits. The DON acknowledged that the failure to follow hold parameters put the resident at risk. Facility policy required medications to be administered in accordance with physician orders, but this was not followed in the case of this resident.