Failure to Follow Physician's Order for Blood Pressure Medication Administration
Penalty
Summary
Facility staff failed to ensure that a resident with Parkinson's Disease and dementia, who was prescribed Midodrine HCL for hypotension, was free from significant medication errors. The physician's order specified that the medication should be held if the resident's systolic blood pressure (SBP) was greater than 115 or diastolic pressure was greater than 80. Despite this, nursing staff administered Midodrine on multiple occasions when the resident's SBP exceeded the prescribed threshold, as documented in the Medication Administration Record (MAR) for May 2025. Nursing documentation showed that the medication was given at least eleven times when the resident's SBP was above 115, contrary to the physician's order. During interviews, both a nurse and the Director of Nursing acknowledged that the medication should not have been administered under these circumstances. The facility's policy required staff to verify medication orders and obtain vital signs as necessary, but these procedures were not followed, resulting in the administration of medication outside the prescribed parameters.