Failure to Follow Medication Holding Parameters for Blood Pressure
Penalty
Summary
The facility failed to ensure that pharmacy services were provided in accordance with physician orders for a resident with hypertension and atrial fibrillation. Specifically, three medications—Benazepril, Terazosin, and Amiodarone—were administered to the resident despite physician orders to hold these medications if the systolic blood pressure (SBP) was below 110 mmHg. Medication Administration Records (MAR) for March and April 2025 showed multiple instances where these medications were given when the resident's SBP was below the specified threshold. The Director of Nursing confirmed that the medications were administered contrary to the holding parameters outlined in the physician's orders. The Consultant Pharmacist stated that he had not reviewed these medications since they were ordered after his most recent medication regimen review. He indicated that, had he identified the issue, he would have recommended a physician review of the blood pressure readings and possible adjustment of the medication regimen. The facility's policy on administering medications requires that medications be given in accordance with prescriber orders, which was not followed in this case.