Failure to Administer Blood Pressure Medication as Ordered
Penalty
Summary
A deficiency occurred when a resident admitted for a 14-day respite stay with diagnoses including heart disease, dementia, and hypertension did not receive their prescribed blood pressure medication, diltiazem, for 10 consecutive days. The physician had changed the order from immediate release diltiazem to a 24-hour extended release formulation, and the DON entered the new order into the electronic medical record. However, the start date for the new medication was incorrectly entered as 10 days later than intended, and the previous order was discontinued on the same day the new order was written. As a result, there was no active order for diltiazem during this period, and the medication was not administered as prescribed. The medication administration record showed no documentation of diltiazem being given during these 10 days, and the resident's blood pressure increased during this time. The DON confirmed the error in the start date and acknowledged that diltiazem is a significant medication that should have been administered daily as ordered.