Failure to Follow Physician's Order for Blood Pressure Medication Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not following a physician's order regarding the administration of Midodrine HCL, a medication prescribed for hypotension. The physician's order specified that the medication should be held if the resident's systolic blood pressure (SBP) was greater than 120. Despite this, staff administered the medication multiple times when the resident's SBP exceeded the specified threshold, as documented in the Medication Administration Record (MAR). Interviews with nursing staff and review of the MAR confirmed that the medication was given outside of the ordered parameters on several occasions, and there was no documentation indicating the medication was held or the reason for holding it when required. The resident involved had diagnoses including cerebral palsy, hyperlipidemia, and acute kidney failure, and was noted to have intact cognition. The care plan directed staff to provide medications and obtain vital signs as ordered. Facility policy required nurses to follow physician orders and check vital signs prior to administering medications with parameters. However, the failure to adhere to these orders and document actions appropriately resulted in significant medication errors, as confirmed by nursing staff and the Director of Nursing during interviews.