Failure to Administer Medication as Ordered for Resident with Hypotension
Penalty
Summary
The facility failed to ensure that medications were administered as ordered by the physician for one resident. Specifically, the resident, who had diagnoses including cervical spinal cord injury, quadriplegia, hypotension, autonomic nervous system disorder, generalized muscle weakness, and depression, did not receive prescribed doses of Midodrine HCL on three occasions. The physician's order specified that Midodrine should be held only if the resident's systolic blood pressure (SBP) was greater than 140. However, the medication was held and not administered when the SBP was exactly 140, which did not meet the criteria for withholding the medication according to the order. Record reviews and staff interviews confirmed that the medication was not given on these occasions, and the staff used a code indicating 'No Med Required - Outside of Parameter' on the Medication Administration Record (MAR). The unit supervisor and administrator both stated that the physician's order was to hold the medication only for SBP greater than 140, and that the nurse should have administered the medication when the SBP was 140. The nurse involved acknowledged that the process required physician notification if the medication was held, but this was not documented in the resident's progress notes.