Failure to Administer PRN Antihypertensive Medication as Ordered
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure the accurate administration of medications for one resident with a diagnosis of hypertension and anxiety disorder. The resident had a physician's order for clonidine HCl 0.2 mg to be administered orally every 8 hours as needed if the systolic blood pressure (SBP) exceeded 160. Record review showed multiple instances where the resident's SBP was above the prescribed threshold, but the medication was not administered as ordered. The medication administration record (MAR) documented several dates and times when the resident's blood pressure was elevated, yet the PRN clonidine was not given. Interviews with staff revealed a lack of awareness and communication regarding the resident's elevated blood pressure readings and the corresponding PRN medication order. Medication aides (MAs) reported that they do not administer PRN medications and that such orders would not appear on their MARs, while licensed vocational nurses (LVNs) indicated they were unaware of the elevated blood pressure readings and relied on MAs to report abnormal values. The facility's policy required medications to be administered safely, timely, and as prescribed, but this was not followed in the case of this resident.