Failure to Administer Hypotension Medication as Ordered and Notify Physician
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a physician's order for a resident's hypotension medication was properly administered. The resident, who had diagnoses including dementia, tachycardia, hypotension, hemiplegia, and Alzheimer's disease, had a physician's order for Midodrine to be given as needed for low blood pressure, with specific parameters for administration. Review of the electronic medical record showed that, over a 67-day period, there were 50 documented opportunities where the resident's blood pressure met the criteria for administration of Midodrine, but there was no documentation that the physician was notified when the medication was not administered as ordered. The medication was only administered on one occasion during this period, despite multiple qualifying blood pressure readings. Further review of the resident's care plan and psychotropic drug use assessment indicated that the resident was at risk for adverse side effects from medications, and staff were expected to monitor for side effects and notify the physician as needed. Interviews with nursing staff confirmed that the expectation was to follow physician orders and document any notifications to the physician if orders were not followed. However, the clinical record lacked evidence of such notifications, and the facility's policy required all medications to be administered as ordered by a healthcare professional.