Failure to Administer PRN Antihypertensive Medication as Ordered
Penalty
Summary
A deficiency occurred when a male resident with diagnoses of hypertension and anxiety disorder did not receive clonidine 0.2 mg as ordered by his physician on nine separate occasions over a period of several weeks. The physician's order specified that clonidine should be administered by mouth every eight hours as needed if the resident's systolic blood pressure (SBP) exceeded 160. Review of the medication administration record (MAR) showed that on multiple dates and times, the resident's SBP was above the prescribed threshold, but the medication was not given as required. Interviews with staff revealed that medication aides (MAs) did not administer PRN medications and that nurses were responsible for this task. One MA stated she was unaware of the clonidine order because it was not listed on her MAR, while a nurse reported she had not been informed of the elevated blood pressures and would begin asking MAs about out-of-range readings. The resident did not report any adverse effects and was unaware of his elevated blood pressure readings. Facility policy required medications to be administered safely, timely, and as prescribed, but this was not followed in this instance.