Failure to Clarify Hold Parameters for Antihypertensive Medications
Penalty
Summary
The facility failed to clarify hold parameters for the administration of amlodipine and lisinopril, both antihypertensive medications, for a resident with diagnoses including type 2 diabetes mellitus and hypertension. The resident's medication orders specified to hold the medications if systolic blood pressure was less than 110 mmHg, but did not include instructions regarding pulse rate. Despite this, the electronic medication administration record prompted nurses to check both blood pressure and pulse prior to administration, and it was standard practice among nursing staff to hold these medications if the pulse rate was less than 60 bpm. However, there were multiple documented instances where the resident received both medications even when their pulse rate was below 60 bpm, as well as instances where the medications were held for low pulse without a corresponding order parameter. Nursing staff, including the RN interviewed, acknowledged that the lack of specific hold parameters for pulse rate in the physician's orders should have prompted them to notify the physician for clarification. The Director of Nursing also confirmed that the orders should have included parameters to hold the medications for low pulse. Facility policy required medications to be administered safely and in accordance with effective order writing, but the absence of clear instructions regarding pulse rate led to inconsistent administration practices and a failure to clarify orders with the physician when indicated.