Failure to Notify Physician of Repeatedly Held Antihypertensive Medications
Penalty
Summary
The facility failed to ensure that physicians were notified regarding the need to alter treatment for two residents who experienced repeated episodes of low blood pressure, resulting in their prescribed antihypertensive medications being held on numerous occasions. For one resident with end stage renal disease and hypertension, the medication Coreg was held 52 out of 60 times in July and 9 out of 12 times in August due to low blood pressure readings, as per physician parameters. Despite this pattern, there was no documentation in the nurse’s notes that the physician had been notified of the frequent holds or the ongoing low blood pressure. Another resident with hypertensive heart disease and heart failure had their metoprolol succinate ER held 7 times in July and 3 times in August for similar reasons. Again, there was no documentation of physician notification in the nurse’s notes, even though the medication was held multiple times due to blood pressure readings falling below the prescribed parameters. Interviews with nursing staff revealed that they believed they had notified the physician, but upon review, no such documentation was found. The Director of Nursing acknowledged during interviews that best practice would be to notify the physician when medications with parameters are held multiple times, or even immediately, and that such notifications should be documented. The facility’s policy required obtaining and recording vital signs and holding medications as ordered, but did not specify the process for physician notification when medications are repeatedly withheld. The lack of documentation and physician notification was confirmed through record review and staff interviews.