Failure to Hold Antihypertensive Medication for Low Pulse
Penalty
Fine: $13,250
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
A resident with a diagnosis of high blood pressure was prescribed antihypertensive medication to be administered twice daily, with specific instructions from the attending provider to hold the medication if the resident's pulse was less than 70. Record review revealed that the resident received the antihypertensive medication on multiple occasions when their pulse was below the specified threshold, including instances where the pulse was recorded as 63, 66, and 64. Staff interviews confirmed that the medication was administered contrary to the physician's order on these dates. The facility's process for reviewing medication administration records was retrospective, and the errors had not been identified prior to the surveyor's review.