Failure to Hold Antihypertensive Medication per Physician Order
Penalty
Summary
A deficiency was identified when a resident with diagnoses of heart failure and primary hypertension was administered antihypertensive medication outside of the parameters ordered by the physician. The physician's order specified that Carvedilol should be held if the resident's heart rate was less than 60 or if the systolic blood pressure was less than 110. Clinical record review showed that on multiple occasions, the medication was administered even when the resident's systolic blood pressure was below the specified threshold, including readings of 92 and 85. There was no documentation indicating that the medication was held as per the physician's order on these dates. The DON confirmed during an interview that the medication was given when the resident's blood pressure was significantly low and acknowledged that it should have been held according to the order. This failure to follow physician orders resulted in a significant medication error for the resident.