Failure to Notify Physician When Medication Was Held
Penalty
Summary
The facility failed to notify a resident's physician when a prescribed medication, Midodrine, was held on multiple occasions. The resident, who had diagnoses including kidney failure, hypotension, and heart failure, was cognitively intact and had a physician's order for Midodrine 5 mg three times daily for hypotension. On specific dates, the medication was not administered due to elevated blood pressure readings, as documented in the Medication Administration Record and nurses' notes. Despite the medication being withheld, there was no documentation that the resident's physician was informed of these omissions. During interviews, an RN expressed uncertainty about administering the medication due to the absence of specific parameters and confirmed that the dose was held when the resident's blood pressure was in the 150s. The Director of Nursing acknowledged the concern but did not provide additional information.