Failure to Hold Blood Pressure Medication per Physician Order
Penalty
Summary
A medication administration error occurred when a resident with a history of hypotension, cognitive impairment, depression, and anxiety received midodrine, an antihypotensive medication, despite their systolic blood pressure (SBP) being above the physician-ordered parameters. The physician's order specified that midodrine should be held if the SBP exceeded 130 mmHg. However, the Medication Administration Record documented multiple instances across several months where the resident received the medication when their SBP was above this threshold. The resident's care plan directed staff to administer medications as ordered and observe for adverse effects, but these instructions were not followed. Staff interviews confirmed that the medication was not held as required, and the certified medication aide administering the medication was unaware that the resident's blood pressure was out of the prescribed range. The facility's policy required immediate reporting and documentation of medication errors, as well as close monitoring of the resident's condition, but the error was only recognized after the fact. The failure to adhere to physician orders and facility policy resulted in the resident receiving medication outside of safe parameters.