Failure to Administer Blood Pressure Medication per Physician Order
Penalty
Summary
A deficiency occurred when a resident did not receive blood pressure medication as ordered by the physician. The physician's order specified that Midodrine HCl 5 mg should be administered orally every 12 hours as needed for hypotension, specifically when the resident's systolic blood pressure was less than 110 mmHg and diastolic blood pressure was less than 60 mmHg. On a specific date, the resident's blood pressure readings were 105/54 mmHg and 102/50 mmHg, both meeting the criteria for medication administration. However, review of the Medication Administration Record (MAR) showed no documentation that the medication was given on that day. Interviews with facility staff revealed that the LPN responsible for the resident did not recall why the medication was not administered and stated that if it had been given, it would have been documented. The Advanced Practice Registered Nurse confirmed that the medication was available and that the parameters for administration were clear. The Director of Nursing also acknowledged that the medication should have been given according to the established parameters. Facility policy required review and adherence to physician orders, which was not followed in this instance.