Failure to Hold Medication per Physician Order for Blood Pressure
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with physician orders for one resident. Specifically, nursing staff did not follow the physician's directive to hold midodrine administration when the resident's systolic blood pressure exceeded 110 mmHg. Documentation in the Medication Administration Record showed that midodrine was given on multiple occasions when the resident's blood pressure readings were above the specified threshold, including readings of 132/80 mmHg, 124/87 mmHg, and 124/76 mmHg. The Director of Nursing confirmed that the nurses did not adhere to the order, acknowledging the error during an interview. The resident involved had a history of hemiplegia and hemiparesis following a cerebral infarction, essential hypertension, and a history of falls. The resident's cognitive skills for daily decisions were severely impaired, and they were dependent on staff for activities such as eating and showering. The facility's policy required medications to be administered as directed by a licensed nurse and upon the order of a physician or licensed independent practitioner, but this policy was not followed in this instance.