Failure to Follow Physician-Ordered Parameters for Midodrine Administration
Penalty
Summary
A deficiency occurred when staff failed to follow physician-ordered parameters for administering Midodrine, a medication used to treat hypotension, to a resident with multiple diagnoses including dementia, tachycardia, hypotension, hemiplegia, and Alzheimer's disease. The physician's order specified that Midodrine should only be administered if the resident's systolic blood pressure was less than 130 mmHg or diastolic blood pressure was less than 60 mmHg, not to exceed three times daily. Review of the resident's electronic medical record and vital signs from March 1 to May 6 showed 50 instances where blood pressure readings met the criteria for administration, but there was no documentation that the physician was notified as required. Additionally, the medication was administered on a date within this period, but the clinical record lacked evidence of proper notification or documentation. Interviews with nursing staff confirmed that the nurse or certified medication aide was responsible for obtaining vital signs before administering medications requiring such checks, and that the nurse should ensure medications are given as ordered. Staff also stated that the physician should be notified if orders are not followed, with documentation in the interdisciplinary notes. The facility's policy required all medications to be administered as ordered by a healthcare professional. The failure to adhere to these protocols resulted in a significant medication error for the resident.