Failure to Administer Blood Pressure Medications per Physician Parameters
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from significant medication errors, as evidenced by the administration of antihypertensive and vasopressor medications outside of physician-ordered parameters for two residents. For one male resident with severe cognitive impairment and a history of hypertension, respiratory failure, and kidney failure, nursing staff administered Carvedilol and Lisinopril despite blood pressure readings below the physician-ordered threshold for holding these medications. Additionally, the same resident received Midodrine, a medication to increase blood pressure, when his systolic blood pressure was above the hold parameter specified in the physician's order. These errors occurred multiple times throughout the month, with specific blood pressure readings and staff members documented for each incident. For a female resident with severe cognitive impairment, anxiety, dementia, and hypertension, staff failed to administer Clonidine as ordered for systolic blood pressure readings over 160. Despite numerous documented episodes of elevated blood pressure that met the criteria for as-needed Clonidine administration, the medication was not given according to the physician's order. The medication administration record confirmed that Clonidine was omitted during each qualifying episode. Interviews with the DON, Medical Director, and Administrator revealed that the expectation was for nurses to follow physician orders and medication parameters, and to check for standing PRN orders when blood pressure readings were abnormal. The DON and Administrator attributed the failures to nurses not paying attention, while the Medical Director expressed concern about the concurrent use of medications with opposing effects and emphasized the importance of adhering to medication parameters. The facility was unable to provide a policy regarding medication administration or following physician orders.