Failure to Hold Antihypertensive Medications per Prescribed Parameters
Penalty
Summary
A deficiency occurred when a cognitively intact female resident with a diagnosis of hypertension received blood pressure medications outside of the prescribed parameters. The resident's physician orders specified that Metoprolol tartrate 25 mg should be held if systolic blood pressure (SBP) was below 100, diastolic blood pressure (DBP) below 60, or heart rate (HR) below 60, and Hydralazine HCL 25 mg should be held if SBP was below 110 or DBP below 60. Despite these clear instructions, medication administration records showed that the resident received Metoprolol and Hydralazine on multiple occasions when her blood pressure and/or heart rate were outside the specified parameters. Interviews with facility staff confirmed that the medications were administered in error. The DON stated that medications should be given according to physician orders, and the administrator expected staff to monitor for accuracy. The nurse involved acknowledged the oversight, attributing it to not paying sufficient attention during medication administration, despite having been educated on the importance of following medication parameters. Facility policy also required medications to be administered as ordered by the prescriber.