Failure to Monitor Blood Pressure Prior to Midodrine Administration
Penalty
Summary
Facility staff failed to monitor and document blood pressure readings prior to administering Midodrine, a medication used to treat low blood pressure, for a resident with a physician's order specifying to hold the medication if systolic blood pressure exceeded 140. The order required blood pressure checks before each dose, but clinical record review showed that on multiple occasions, blood pressure was not obtained prior to administration at scheduled times. This included several missed checks for both morning and afternoon doses across different dates. Staff interviews confirmed that blood pressure should have been checked before each administration to ensure the medication was given within the prescribed parameters. Facility policy also required verification of vital signs prior to medication administration when necessary. Despite these requirements, documentation and monitoring were not consistently performed, resulting in the administration of medication without the necessary assessment.