Failure to Hold Antihypertensive Medication per Physician Order
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of hypertension received a blood pressure medication, Amlodipine Besylate 5 mg, despite physician orders specifying the medication should be held if the resident's systolic blood pressure (SBP) was less than 130. Review of the Medication Administration Record (MAR) showed that the medication was administered on multiple occasions when the resident's documented SBP was below the ordered threshold, including readings of 111/92 and 123/75. The facility's policy required verification of physician orders and performance of necessary evaluations, such as blood pressure checks, prior to medication administration. Interviews with facility staff confirmed that the medication should not have been given based on the recorded blood pressure readings. The LPN could not explain why the medication was administered despite the low SBP, and the DON acknowledged that the medication should have been held according to the physician's order and facility policy. This failure resulted in the resident receiving unnecessary medication.