Failure to Adhere to Blood Pressure Medication Parameters
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary medications. A review of medical orders showed that the resident, who had a diagnosis of hypertension, was prescribed a blood pressure medication to be administered every morning and at bedtime, with explicit instructions to hold the medication if the systolic blood pressure was less than 120. Despite these parameters, the medication was administered on multiple occasions when the resident’s systolic blood pressure was below the specified threshold. A review of the electronic Medication Administration Record (eMAR) for April 2025 revealed that the blood pressure medication was given outside the prescribed parameters on several dates and times. The DON confirmed during an interview that the medication was administered inappropriately on these occasions, as indicated by the eMAR documentation.