Failure to Administer Blood Pressure Medication per Physician Orders
Penalty
Summary
A deficiency occurred when a resident with diagnoses including congestive heart failure, dementia, diabetes mellitus, and hypertension did not receive blood pressure medication according to the physician's orders. The care plan specified the need for medications as ordered and monitoring for cardiovascular distress. The physician's order required that furosemide 20 mg be administered daily but held if the resident's systolic blood pressure was less than 120. Despite this, the Medication Administration Record showed that the medication was given multiple times when the resident's systolic blood pressure was below the specified threshold. Interviews with nursing staff and the DON confirmed that the medication should have been withheld when the resident's blood pressure was outside the ordered parameters. Facility policy required that current orders, including standing orders, be maintained and followed as documented in the electronic clinical record. The failure to hold the medication as ordered resulted in the administration of furosemide outside of the physician's specified parameters.