Failure to Hold Blood Pressure Medications per Physician Parameters
Penalty
Summary
Staff failed to follow physician-ordered parameters for administering blood pressure medications to a resident with a history of acute combined systolic and diastolic heart failure. The resident had orders for Isosorbide Mononitrate and Lisinopril, both with explicit instructions to hold the medication if the systolic blood pressure (SBP) was less than 120 mmHg or the heart rate was less than 60 beats per minute. Despite these orders, medication administration records showed that these medications were given on multiple occasions when the resident's SBP was below the prescribed threshold. Interviews with nursing staff revealed a lack of clarity and adherence to the specific parameters outlined in the physician's orders. Several nurses admitted to administering the medications when the resident's SBP was below 120 mmHg, with some staff mistakenly believing the hold parameter was 110 mmHg. Others acknowledged that they may have documented administration even when the medication was actually held, indicating inconsistencies in both practice and documentation. The Director of Nursing and the Administrator confirmed that medications should not have been administered outside of the prescribed parameters and that proper documentation was not consistently completed. The facility's policy required staff to obtain and record vital signs prior to medication administration and to follow all physician orders. However, the review of records and staff interviews demonstrated that these procedures were not consistently followed, resulting in significant medication errors for the resident. No medication error reports were completed for these incidents, and the Medical Director was only notified after the issue was identified during the review.