Failure to Hold Blood Pressure Medications per Physician Parameters
Penalty
Summary
The facility failed to ensure that blood pressure medications were administered according to physician-ordered parameters for a resident with multiple diagnoses, including congestive heart failure, atrial fibrillation, diabetes, and hypertension. The resident was prescribed Metoprolol tartrate with instructions to hold the medication if systolic blood pressure was less than 120 mmHg or pulse was less than 60 bpm, and Midodrine hydrochloride with instructions to hold if systolic blood pressure was greater than 120 mmHg. Medical record review showed that these parameters were not followed on multiple occasions, with Metoprolol administered when the resident's systolic blood pressure was below 120 mmHg and Midodrine given when systolic blood pressure was above 120 mmHg. Interviews with nursing staff and facility leadership confirmed that both medications were administered despite blood pressure readings that met the criteria for holding the medications. The medication administration record documented several instances where the medications were not held as ordered, and both the LPN and DON acknowledged that the medications should have been held based on the resident's blood pressure readings. This failure resulted in significant medication errors for the resident.