Failure to Follow Physician's Order for Blood Pressure Medication
Penalty
Summary
The facility failed to follow a physician's order regarding the administration of losartan for a resident with a history of syncope and hypertension. The physician's order specified that losartan should be held if the resident's systolic blood pressure (SBP) was less than 110 mmHg. Despite this, documentation showed that the resident received losartan on two occasions when her SBP was recorded as 105 mmHg and 100 mmHg, both below the threshold set by the physician. A review of the resident's records confirmed that the medication was administered contrary to the order, and this was acknowledged by the Licensed Vocational Nurse (LVN) involved, who stated that the medication should not have been given under those circumstances. The facility's policy on medication administration requires that medications be given in accordance with physician orders, which was not followed in this instance.