Failure to Administer PRN Antihypertensive Medication per Physician Order
Penalty
Summary
A deficiency occurred when facility staff failed to follow physician orders for blood pressure monitoring and administration of antihypertensive medication for a resident diagnosed with hypertension. The resident had multiple active orders for blood pressure medications, including a PRN order for clonidine to be administered when systolic blood pressure (SBP) exceeded 160 mmHg. Despite several documented instances where the resident's SBP was above this threshold, the clonidine was not administered as ordered, and there were no progress notes addressing these elevated readings. The electronic medication administration record confirmed that clonidine had not been given since the start of the order. Interviews with staff revealed a lack of awareness regarding the resident's PRN blood pressure medication orders. Certified Medication Aides (CMAs) reported only notifying nurses if the SBP was 190 mmHg or higher, contrary to the physician's order. Licensed nursing staff were also unaware of the PRN order for clonidine. Administrative nursing staff acknowledged that blood pressure monitoring was not being conducted as required and verified that the medication was not administered when indicated. The facility did not provide a policy related to this process.