Failure to Hold Medications for Low Blood Pressure
Penalty
Summary
A deficiency occurred when a resident with a history of congestive heart failure and moderate cognitive impairment was administered medications despite physician orders specifying blood pressure parameters. The resident's orders for Lasix and spironolactone included instructions to hold the medications if the systolic blood pressure (SBP) was less than 110. However, multiple entries in the Medication Administration Record (MAR) over several months showed that the resident received these medications even when their SBP was below the prescribed threshold. Nursing staff interviews confirmed that they were expected to check and follow medication parameters before administration. Despite this expectation, the MAR documented several instances where the resident was given Lasix and/or spironolactone when their SBP was less than 110, contrary to the physician's orders. Facility leadership, including the unit manager and Director of Nursing, acknowledged that these parameters should have been followed and that the medications should have been held when the resident's blood pressure was below the specified limit.