Failure to Hold Blood Pressure Medication per Physician Parameters
Penalty
Summary
Staff failed to follow physician-ordered parameters for administering blood pressure medication to a resident with multiple diagnoses, including dementia, anxiety, edema, and hypertension. The physician's order specified that atenolol should be held if the resident's systolic blood pressure was less than 110 mmHg or diastolic blood pressure was less than 60 mmHg. Despite these clear instructions, the Medication Administration Record showed that the resident received atenolol on several occasions when blood pressure readings were outside the ordered parameters. Interviews with staff confirmed that the medication should have been held when blood pressure readings were out of range, and that the Certified Medication Aide was expected to notify a nurse in such cases. The facility's policy required staff to check vital signs and follow medication guidelines as ordered. However, these procedures were not followed, resulting in the resident receiving unnecessary medication contrary to physician orders.