Failure to Prevent Administration of Unnecessary Antihypertensive Medications
Penalty
Summary
The facility failed to ensure that two residents' drug regimens were free from unnecessary drugs, specifically regarding the administration of antihypertensive medication. For one resident with a diagnosis of essential hypertension, a physician's order specified that Hydralazine 50 mg should be administered only if the systolic blood pressure (SBP) was greater than 160. However, medication administration records showed that the resident received Hydralazine multiple times when their SBP was below 160, with readings as low as 117. This was acknowledged by an LPN during a surveyor interview, confirming that the medication was given contrary to the physician's order. Another resident, also diagnosed with essential hypertension, had a physician's order for Hydralazine 25 mg every six hours, to be held if the SBP was less than 110. Despite this, records indicated that the medication was administered on several occasions when the resident's SBP was below 110, with readings as low as 88. This was similarly acknowledged by another LPN. The Director of Nursing Services was unable to provide evidence that these residents were free from unnecessary medications, as required.