Failure to Hold Blood Pressure Medication per Physician Order
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary medications by not following a physician’s order regarding the administration of midodrine, a blood pressure support medication. The physician’s order specified that midodrine 10 mg should be administered every 12 hours for hypotension, but the medication was to be held if the resident’s systolic blood pressure (SBP) was greater than 120 mmHg. Despite this, medical record review showed that the resident received midodrine on multiple occasions when their SBP exceeded the specified threshold, with documented SBP readings ranging from 121 to 132 mmHg at the time of administration. Interviews with both an LVN and the DON confirmed that the facility’s policy required licensed nurses to check for any BP parameters in the physician’s order and to hold the medication if the resident’s BP was outside those parameters. Both staff members acknowledged that the medication was administered and documented in the MAR even when the SBP was above the ordered limit. The DON verified the findings during a review of the resident’s medical record and MAR, confirming that the medication should have been held on the identified dates and times.