Blood Pressure Medication Administered Outside Physician Parameters
Penalty
Summary
The facility failed to ensure that blood pressure medication was administered according to physician-ordered parameters for a resident with hypertension and congestive heart failure. The physician's order specified that clonidine hydrochloride should be held if the systolic blood pressure was less than 130 or if the heart rate was less than 60. Despite these clear parameters, the medication was repeatedly administered when the resident's blood pressure and/or heart rate were below the specified thresholds, as documented in the Medication Administration Record for multiple dates in April and May. The resident had a moderately impaired cognition, as indicated by a BIMS score of 8 out of 15, and was being treated for hypertension related to congestive heart failure. Interviews with nursing staff, including an LPN and the DON, confirmed that the medication was given outside of the prescribed parameters and acknowledged that the physician's orders were not followed. The facility's policy required medications to be administered as prescribed, including adherence to any parameters set by the prescriber. The deficiency was identified through review of medical records, staff interviews, and facility policy, all of which confirmed that the medication administration did not comply with the physician's orders.