Failure to Adhere to Physician-Ordered Blood Pressure Parameters During Medication Administration
Penalty
Summary
A deficiency occurred when a certified medication technician (CMT) administered Lisinopril 20 mg to a resident diagnosed with essential hypertension, Alzheimer's disease, and chronic kidney disease, despite the physician's order to hold the medication if the resident's systolic blood pressure was less than 150 mm Hg. On the observed date, the resident's systolic blood pressure was 132 mm Hg, yet the medication was still given. The CMT later realized the error after reviewing the medication parameters and acknowledged that the medication should not have been administered. The facility's policy required medications to be administered as ordered and for vital signs to be checked and recorded, with medications held if outside prescribed parameters. Further review of the resident's Medication Administration Record (MAR) revealed that Lisinopril had been administered on multiple occasions when the resident's systolic blood pressure was below the ordered threshold of 150 mm Hg. Specifically, in the month of May, the medication was given 21 times despite the highest recorded systolic blood pressure being 136 mm Hg, and in June, it was administered on three occasions with all readings below 150 mm Hg. Interviews with staff indicated a misunderstanding of the hold parameters, with the CMT and nursing leadership referencing more common lower thresholds, rather than the specific order for this resident.