Failure to Notify Physician and Hold Antihypertensive Medication for Hypotensive Resident
Penalty
Summary
Facility staff failed to notify a resident's physician regarding a significantly low blood pressure reading and administered an antihypertensive medication despite the hypotensive state. The resident, who had diagnoses of hypertension, Alzheimer's disease, and schizophrenia, was prescribed two antihypertensive medications: losartan potassium and atenolol. On the day in question, the resident's blood pressure was recorded as 78/67, which is below the normal range. The Certified Medication Technician (CMT) documented this low blood pressure but did not notify the charge nurse or hold the antihypertensive medication as required by facility policy. The resident's care plan and physician orders indicated that blood pressure should be monitored, and antihypertensive medications should be held if hypotension occurred, with prompt notification to the physician. Despite these directives, the CMT administered losartan potassium and failed to communicate the low blood pressure to nursing staff. There was no documentation in the progress notes regarding the hypotensive episode, and the charge nurse was not made aware of the situation until after the resident experienced a medical emergency. Interviews with facility staff, including the LPN, DON, RN, and the resident's physician, confirmed that the expected protocol was not followed. The CMT should have held the antihypertensive medication and immediately informed the nurse, who would then have contacted the physician for further orders. The physician stated that, had he been notified, he would have ordered emergency interventions. The lack of communication and failure to follow established protocols directly contributed to the deficiency identified during the survey.