Failure to Follow Physician-Ordered Hold Parameters for Midodrine Administration
Penalty
Summary
The facility failed to ensure that physician-ordered parameters for the administration of Midodrine, a medication used to treat hypotension, were followed for two residents. For both residents, the physician's order specified that Midodrine should be held if the systolic blood pressure (SBP) was greater than 100. Despite these clear instructions, the medication was administered outside of these parameters on 13 separate occasions for each resident, as confirmed by a review of the Medication Administration Records (MAR) and interviews with the Director of Nursing (DON). The DON acknowledged that the medication was given in error and outside of the prescribed parameters on the specified dates. Interviews with nursing staff confirmed their awareness of the hold parameters and the importance of not administering Midodrine when the SBP exceeded 100, as per the physician's orders. The facility's policy on medication administration required that medications be given as prescribed and that vital signs, including blood pressure, be checked and verified prior to administration. Despite these policies and staff knowledge, the medication was repeatedly administered inappropriately, as documented in the MAR and confirmed by the DON.