Failure to Hold Blood Pressure Medication per Physician Order
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of hypotension received Midodrine HCl, a blood pressure medication, despite physician orders specifying that the medication should be held if the resident's systolic blood pressure (SBP) was greater than 120. The medication administration record showed multiple instances where the medication was given when the resident's SBP exceeded the ordered hold parameter, with recorded SBP values ranging from 125 to 141 at the time of administration. During interviews, a Qualified Medication Aide confirmed that medications should be held if the resident's blood pressure is outside the physician's ordered parameters. The Director of Nursing provided a copy of the facility's medication administration policy, which states that medications are to be administered only as prescribed by the provider. The failure to follow the physician's order for holding the medication was identified during a review of the resident's clinical record and medication administration documentation.