Failure to Adhere to Medication Administration Parameters for Antihypertensive
Penalty
Summary
Nursing staff failed to administer medication in accordance with physician orders for a resident with hypertension. The resident had a physician order for Lotrel, an antihypertensive medication, to be held if the systolic blood pressure (SBP) was less than 110 or heart rate was less than 60. Despite this, review of the Medication Administration Record showed that Lotrel was administered on multiple occasions when the resident's SBP was below the ordered threshold. Documentation indicated that an LPN was responsible for administering the medication on most of these occasions. A pharmacy consultation report identified the issue and recommended that staff be reminded of the importance of adhering to medication administration parameters. However, the DON, who signed the pharmacy recommendation, reported not recalling the recommendation and confirmed that no follow-up education or action was taken to ensure staff compliance with the ordered parameters. The facility's own policy requires medications to be administered according to physician orders, but this was not followed in this case.