Failure to Follow Physician-Ordered Blood Pressure Parameters for Antihypertensive Medications
Penalty
Summary
The facility failed to ensure that physician-ordered parameters for administering hypertension medications were followed for two residents. For one resident, the physician's order specified that Olmesartan Medoxomil should be held if the systolic blood pressure (SBP) was less than 130. However, review of the Medication Administration Record (MAR) showed that the medication was administered on multiple occasions when the resident's SBP was below the ordered threshold, with documented readings of 121/63, 121/66, 114/63, 129/62, and 124/62. The Director of Nursing confirmed that the medication was given outside the prescribed parameters on these dates. In another instance, an LPN prepared to administer Losartan to a resident after obtaining a manual blood pressure reading of 128/78, despite a physician order to hold the medication for SBP less than 130. The LPN stated she was accustomed to looking for lower SBP parameters and did not notice the specific threshold of 130 in this order. The facility's policy requires medications to be administered as prescribed and for staff to follow the five rights of medication administration, but these protocols were not followed in these cases.