Failure to Monitor and Administer Midodrine per Physician Orders
Penalty
Summary
Staff failed to ensure proper blood pressure monitoring and administration of midodrine for a resident diagnosed with hypotension. The resident's care plan and physician's order required staff to check blood pressure before administering midodrine, only give the medication if the systolic blood pressure (SBP) was less than 100 mm/Hg, and ensure the resident was sitting upright during administration. The care plan also instructed staff not to give the medication while the resident was lying down or within four hours of bedtime. Record review showed that on two occasions, the resident's SBP was below 100 mm/Hg, but midodrine was not administered and the physician was not notified as required. Additionally, staff interviews revealed a lack of awareness of the medication order and the need to notify the provider for out-of-range blood pressures. Observations also indicated that the resident was assisted to lie down after eating, which could conflict with the care plan instructions regarding medication administration.