Failure to Administer Antihypotensive Medication as Ordered
Penalty
Summary
A resident with a history of hypotension and impaired cognition was admitted to the facility and had a physician's order for Midodrine HCl, an antihypotensive medication, to be administered twice daily when systolic blood pressure (SBP) was less than or equal to 120. Review of the Medication Administration Record (MAR) for February 2025 showed that the resident did not receive the prescribed medication on multiple dates when the SBP was below the threshold, as required by the physician's order. The medication was omitted without documentation of physician notification or clinical justification. Interviews with the DON and a licensed nurse confirmed that the expectation was to follow physician orders and to notify the physician if a medication was not administered. The licensed nurse acknowledged that the resident's SBP was below 120 on the missed dates and that the medication should have been given. Facility policy required medications to be administered as prescribed and for the prescriber to be contacted if there were concerns about the appropriateness of a dosage. These actions and inactions resulted in a significant medication error for the resident.