Failure to Hold Blood Pressure Medications per Physician Orders
Penalty
Summary
Nursing staff failed to follow physician orders regarding blood pressure medication administration for a resident with diagnoses including congestive heart failure, coronary artery disease, and hypertension. The resident had specific physician orders for Amlodipine, Isosorbide Mononitrate Extended Release, and Carvedilol, each with parameters to hold the medication if the resident's systolic or diastolic blood pressure fell below certain thresholds. Despite these orders, medication administration records showed that the resident received these medications on multiple occasions when their blood pressure readings were below the specified parameters. Interviews with medication aides and review of the medication administration record confirmed that the medications were given outside of the ordered parameters, with one aide acknowledging the administration as an oversight. The Medical Director stated that while a few doses outside parameters may not have caused serious harm, he expected staff to follow the written orders. The facility's Administrator and Director of Nursing also confirmed their expectation that staff adhere to medication hold parameters as ordered by the physician.