Failure to Administer Antihypertensive Medication Resulting in Hospital Transfer
Penalty
Summary
A significant medication error occurred when a resident with a history of hypertension and heart failure did not receive 14 doses of a physician-ordered antihypertensive medication, Entresto, over several days. The medication was documented as not administered or unavailable on multiple occasions, with corresponding entries in the Medication Administration Record (MAR) and progress notes. Despite the repeated lack of administration, there was no documentation that the physician was notified about the unavailability of the medication, and the medication was not obtained from the pharmacy or backup supply in a timely manner. The resident subsequently experienced uncontrolled hypertension, presenting with symptoms such as dizziness, generalized weakness, and markedly elevated blood pressure, which led to an emergency hospital transfer. Hospital records indicated a diagnosis of hypertensive emergency, and the medical team questioned compliance with prescribed medications, noting the absence of an exact substitute for Entresto. Interviews with nursing staff confirmed that the medication was not available and not administered, and that there was no documentation of physician notification regarding the missed doses. Further review revealed inconsistencies in MAR documentation, such as doses being marked as administered when the medication was not available, and the use of codes without corresponding physician orders. The Director of Nursing and other facility leadership acknowledged that medication should not be checked off as administered if not given and that the physician should be contacted if a medication is unavailable for several days. However, there was no evidence that the facility conducted a timely review or investigation of the incident prior to the survey, and leadership was unaware of the missed medication administration until informed by surveyors.