Failure to Follow Physician Orders for Blood Pressure Medication Hold Parameters
Penalty
Summary
The facility failed to follow physician orders regarding medication hold parameters for two residents diagnosed with hypertension. For one resident, the physician ordered atenolol 25 mg daily to be held if the systolic blood pressure (SBP) was less than 120. Despite this, the medication was administered on multiple occasions when the resident's SBP was below the specified threshold, with recorded SBP values ranging from 89 to 118 on several dates. The medication administration records (EMAR) confirmed these instances, and staff interviews indicated an understanding that blood pressure medications should be held if readings fall outside physician-ordered parameters. Similarly, another resident with hypertension was prescribed metoprolol 12.5 mg twice daily, also to be held for SBP less than 120. The EMAR showed that this medication was administered on several occasions when the resident's SBP was below 120, with values between 111 and 119. Facility policy requires medications to be administered as prescribed and in accordance with physician orders, but these orders were not followed in the cases reviewed.