Failure to Follow Medication Hold Parameters for Blood Pressure Medication
Penalty
Summary
The facility failed to ensure safe monitoring and assessment of blood pressure and heart rate for a resident prescribed Midodrine, a medication used to treat low blood pressure. The physician's order specified that Midodrine should be held if the resident's systolic blood pressure exceeded 120 mmHg. Despite this, the medication was administered on seven occasions when the resident's systolic blood pressure was above the ordered threshold. This was confirmed through review of the resident's Medication Administration Record (MAR) and interviews with a licensed nurse and the Director of Nursing, both of whom acknowledged that the medication should not have been given under these circumstances. The resident involved had a medical history including hypertensive heart disease with heart failure and acute on chronic systolic congestive heart failure. The facility's policy required compliance with medication administration parameters and documentation of any medication errors, including notifying the physician and supervisor. However, there was no documentation in the resident's medical record of the seven medication errors, nor was the Director of Nursing made aware of these errors at the time they occurred.