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F0658
D

Failure to Follow Prescriber Parameters for Blood Pressure Medication

Sonoma, California Survey Completed on 07-18-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident with diagnoses including lung cancer, chronic lung disease, heart failure, and hypertension was administered doxazosin mesylate, a blood pressure medication, despite prescriber orders to hold the medication if the resident's systolic blood pressure (SBP) was less than 100 or pulse was less than 60. Medication Administration Records (MARs) showed that the medication was given on three occasions when the resident's SBP was below the ordered parameter: 99, 93, and 96, respectively. Interviews with a licensed nurse and the Director of Nursing confirmed that the medication should have been held on those dates, as per the physician's order and facility policy. Both staff members acknowledged the importance of following medication parameters to prevent adverse effects. The facility's policy required medications to be administered in accordance with prescriber orders, and the failure to do so resulted in the identified deficiency.

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