Failure to Adhere to Physician-Ordered Parameters for Antihypertensive Medication
Penalty
Summary
Facility staff failed to ensure that a resident’s drug regimen was free from unnecessary medications by not adhering to physician-ordered parameters for administering hydralazine, an antihypertensive medication. The physician’s order specified that hydralazine should be held if the resident’s systolic blood pressure (SBP) was less than 140. Despite this, the medication administration record (MAR) showed that the resident received hydralazine on three occasions when their SBP was below the prescribed threshold (134, 137, and 138). These administrations were documented with check marks on the MAR, indicating the medication was given outside of the ordered parameters. A nurse’s note confirmed that the medication was administered outside of the prescribed parameters and that the nurse practitioner and responsible party were made aware. During an interview, an LPN acknowledged that the medication should not have been given on those dates, as the nurses did not pay attention to the physician’s hold parameter. The facility’s policy requires medications to be administered in accordance with prescriber orders, but this was not followed in this instance.