Failure to Hold Blood Pressure Medication per Physician Parameters
Penalty
Summary
Staff failed to follow physician-ordered parameters for administering blood pressure medication to a resident with a history of hypotension, cognitive impairment, depression, and anxiety. The physician's order specified that midodrine should be held if the resident's systolic blood pressure (SBP) exceeded 130 mmHg. Despite this, the Medication Administration Record showed multiple instances over several months where the medication was administered when the resident's SBP was above the ordered threshold. The resident's care plan directed staff to administer medications as ordered and observe for adverse effects, but these instructions were not followed. Certified Medication Aides and Licensed Nurses involved in the resident's care did not recognize or act upon the out-of-parameter blood pressure readings, resulting in the medication being given inappropriately. Staff interviews confirmed a lack of awareness regarding the need to hold the medication when the SBP was above the specified limit. The facility's policy required medications to be administered as prescribed and in accordance with written orders, but this was not adhered to in the resident's case.