Failure to Administer Prescribed Medication for Hypotension Resulting in Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to administer a physician-prescribed medication, Midodrine 10 mg, to a resident with a diagnosis of hypotension and other mobility-related conditions. The resident was prescribed Midodrine to be given when systolic blood pressure dropped below 95 mm/Hg. Review of the resident's blood pressure logs showed multiple instances of systolic blood pressure below this threshold, but the medication administration record (MAR) did not document that Midodrine was given on those occasions. The Director of Nursing confirmed that if the medication was not documented as administered on the MAR, it was not given, and stated that the expectation is to follow the physician's order for as-needed medication. As a result of this failure, the resident experienced an episode of hypotension with a blood pressure reading of 85/63 mm/Hg and subsequently fell, sustaining lacerations to the forehead and left arm. The facility's medication pass policy requires adherence to physician orders and proper documentation on the MAR after medication administration. The failure to administer the prescribed medication as ordered directly contributed to the resident's hypotensive episode and fall.