Failure to Administer Clonidine as Ordered for Hypertensive Resident
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not administering clonidine as ordered for high blood pressure. The medication order specified that clonidine 0.1 mg should be given by mouth every six hours as needed for systolic blood pressure greater than 150. Review of the Medication Administration Records (MAR) for March, April, May, and June showed that although blood pressure was checked every six hours as ordered, there were 33 instances where clonidine was not administered when indicated, as evidenced by blank spaces on the MAR where nurse initials should have been recorded after administration. The resident involved had a history of hypertension, cardiac arrhythmia, and hyperkalemia, and required substantial to maximal assistance with activities of daily living. Interviews with the resident revealed that he was not aware of whether clonidine was given and relied on nursing staff for medication administration. An LVN confirmed that the medication was not given as ordered and acknowledged the potential for serious consequences. Facility policy required medications to be administered according to physician orders and for the MAR to be properly documented, which was not followed in this case.