Failure to Monitor Blood Pressure Prior to Antihypertensive Medication Administration
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary drugs by not adhering to physician orders regarding blood pressure monitoring prior to administering antihypertensive medications. For one resident with an order for Losartan Potassium to be held if systolic blood pressure (SBP) was less than 110, the medication was administered on two occasions when the SBP was 104, as documented in the Medication Administration Record (MAR), with no notes indicating the medication was held or any justification for administration outside of parameters. A nurse practitioner later ordered the medication to be stopped due to hypotension. For another resident prescribed Metoprolol Tartrate with instructions to hold for SBP less than 110 or heart rate less than 60, blood pressure was not consistently monitored or documented prior to administration. Review of the MARs over several months showed that blood pressure was only checked a small fraction of the times the medication was given, and the medication was administered at least once when the SBP was below the ordered threshold. Staff interviews confirmed that blood pressure was not always documented before medication administration, and the DON and Medical Director acknowledged the issue.