Failure to Hold Medication per Blood Pressure Parameters
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
A resident with hypertensive heart disease and orthostatic hypotension was admitted to the facility and prescribed midodrine 10 mg three times daily, with specific instructions to hold the medication if the systolic blood pressure exceeded 130 mm Hg. Review of the Medication Administration Records for June and July 2025 showed that the resident received midodrine on multiple occasions when their systolic blood pressure was above the ordered threshold, contrary to the physician's instructions. During interviews, a registered nurse confirmed that the medication was administered despite the parameters, and the Director of Nursing Services was unable to provide evidence that the medication was held as ordered.