Failure to Hold Antihypertensive Medication for Low Blood Pressure
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of hypertension received blood pressure medication, Lisinopril 10 mg daily, despite physician orders specifying that the medication should be held if the resident's systolic blood pressure (SBP) was less than 110. The resident's care plan indicated altered cardiovascular status due to hypertension, and the medication administration record showed multiple instances where the medication was administered even though the resident's SBP was below the ordered threshold. Specifically, the medication was given on several dates when the SBP ranged from 100 to 109, all below the physician's specified parameter. During interviews, nursing staff confirmed that medications should not be administered if vital signs are out of the ordered parameters. Facility policy also required that medications be administered in accordance with physician orders and that vital signs be obtained and recorded as necessary prior to administration. Despite these requirements, the medication was not held as ordered, resulting in a failure to provide care according to the resident's clinical needs and physician instructions.