Failure to Notify Practitioner Before Administering Anti-Hypertensive Medication to Resident with Critically Low Blood Pressure
Penalty
Summary
The facility failed to ensure that a nurse practitioner or physician was notified prior to administering a medication with anti-hypertensive properties to a resident with a critically low blood pressure. The resident had a complex medical history, including hypertensive heart disease, paroxysmal atrial fibrillation, atherosclerotic heart disease, malignant neoplasm of the scrotum and prepuce, and pleural effusion. On the morning in question, the resident's blood pressure was recorded at 70/50 mm Hg and pulse at 59 bpm, yet both midodrine and metoprolol tartrate were administered. The facility's policy required consultation with the medical practitioner when there was a change in condition, such as a deterioration of health status or a need to alter treatment, but this was not followed. Nursing documentation showed that the nurse practitioner was only notified after the medications were given. The nurse who administered the metoprolol stated she did not contact the physician or nurse practitioner beforehand, citing past instructions to administer the medication to other residents with similar vital signs, though she could not provide specifics. The nurse practitioner confirmed that she should have been contacted prior to administration, as the medication could further lower blood pressure, and stated she would have instructed the nurse to hold the medication. The resident subsequently experienced severe symptoms, including hypoxia, lethargy, and critically low oxygen saturation, requiring emergency transfer to the hospital.