Failure to Adhere to Blood Pressure Parameters for Antihypertensive Medication
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident was free from significant medication errors related to the administration of Hydrochlorothiazide, a medication prescribed for hypertension. The resident, an older adult male with diagnoses including Wernicke's Encephalopathy, dementia with mood disorder, and essential hypertension, had physician orders specifying that Hydrochlorothiazide should be held if blood pressure was less than 100/60. However, there were inconsistencies in the medication orders, with some periods lacking clear blood pressure parameters, and the facility did not clarify these discrepancies with the provider. Medication administration records revealed that Hydrochlorothiazide was given to the resident even when his blood pressure readings were below the prescribed parameters, such as on occasions when his blood pressure was 124/54 and 98/62. Additionally, there were several days when no blood pressure readings were documented prior to administration of the medication, despite the order requiring this assessment. Interviews with nursing staff indicated a lack of awareness or attention to the blood pressure parameters, and some staff could not recall receiving recent in-service training on this topic, though they mentioned annual skills checkoffs. The facility's medication administration policy required obtaining and recording vital signs when applicable, holding medications for vital signs outside prescribed parameters, and documenting these on the medication administration record. Despite these policies, the staff failed to consistently follow the prescribed parameters for Hydrochlorothiazide, leading to the administration of the medication outside of safe blood pressure ranges and without proper documentation.