Failure to Hold Antihypertensive Medication per Physician Order
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including congestive heart failure, hypertension, dementia, diabetes, and cerebral infarction, received anti-hypertensive medication that did not comply with the physician's ordered blood pressure parameters. The resident's care plan specified a goal for blood pressure to remain within normal limits, and the physician's order directed that Hydralazine should be held if the systolic blood pressure (SBP) was less than 130. Despite this, medication administration records showed that Hydralazine was given on several occasions when the resident's SBP was below the ordered threshold. During an interview and record review, the Interim Director of Nursing confirmed that the medication should have been held according to the physician's order and that nurses are expected to follow these orders. Facility policy also requires medications to be administered in accordance with physician orders.