Medication Error Due to Omission of Hold Parameters in Furosemide Order
Penalty
Summary
A deficiency occurred when a resident with a history of benign prostatic hyperplasia, hypothyroidism, and cerebral palsy was not administered their prescribed furosemide medication as ordered. During a medication pass, an LVN held the resident's furosemide dose based on a systolic blood pressure reading of less than 100, despite the current medication order lacking any hold parameters. The LVN referenced a previous order that included such parameters, but the renewed order did not specify them, leading to the medication being withheld without proper authorization. Record review and interviews confirmed that the medication order for furosemide, renewed in the electronic medical administration record (E-MAR), did not include instructions to hold the medication for low blood pressure. The facility's policy requires all medications to be administered as prescribed and properly documented, and deviations such as this are considered medication errors. The Chief Nursing Officer acknowledged that this was a system error related to the communication and entry of the renewed order into the E-MAR.