Incorrect Medication Order Instructions for Blood Pressure Management
Penalty
No penalty information released
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Summary
The facility failed to ensure that a medication order for a resident was written with the correct instructions for its intended use. A review of the medical record showed that a resident with hypotension and dependence on renal dialysis was prescribed Midodrine 10 mg to be administered three times daily for low blood pressure, with instructions to hold the medication if the systolic blood pressure (SBP) was less than 110 mmHg. During an interview, the DON confirmed that the order did not accurately reflect the intended use of the medication, as Midodrine should be held when SBP is elevated, not when it is low. This discrepancy in the physician's order was identified during a complaint investigation.