Failure to Hold Antihypertensive Medication per Physician Order
Penalty
Summary
Nursing staff failed to follow physician orders regarding the administration of a blood pressure medication for a resident with hypertensive heart disease and heart failure. The physician's order specified that losartan potassium-hydrochlorothiazide should be held if the resident's systolic blood pressure (SBP) was less than 110. Despite this, medication administration records showed that the medication was given on multiple occasions when the resident's SBP was below the specified threshold. These instances occurred over several months and involved multiple nurses, who either acknowledged the oversight or could not recall the reason for administering the medication outside the prescribed parameters. The resident in question had severe cognitive impairment, as documented in the Minimum Data Set assessment. Interviews with nursing staff confirmed awareness of the medication parameters, yet the medication was still administered inappropriately. The nurse practitioner stated that, while no serious harm was expected from these incidents, she expected the nursing staff to follow the medication order as written. The Director of Nursing also confirmed that staff are expected to adhere to physician orders, including those with specific hold parameters.