Failure to Hold Blood Pressure Medication per Physician Order
Penalty
Summary
Facility staff failed to follow physician orders regarding the administration of Midodrine for a resident who required extensive assistance with daily activities and had a pressure ulcer. The resident's medication order specified that Midodrine 5 mg should be held if the systolic blood pressure (SBP) was above 120. However, medication administration records for August and September showed that the drug was administered multiple times when the resident's SBP exceeded the prescribed threshold. The Director of Nursing confirmed that the medication should have been held on the identified dates when the SBP was above 120, as per the physician's order. Facility policy requires staff to follow physician and non-physician provider orders, and failure to do so may result in a medication discrepancy. The report documents that the staff did not adhere to these guidelines, resulting in the administration of unnecessary medication.