Failure to Follow Medication Hold Parameters for Blood Pressure Medication
Penalty
Summary
The facility failed to ensure that the parameters for administering midodrine, a medication used to treat low blood pressure, were correctly entered into the medical record and followed during administration for a resident with multiple diagnoses including Alzheimer's disease, neuromuscular dysfunction, dysphagia, type 2 diabetes, schizoaffective disorder/bipolar type, and depressive disorder. The physician's order specified that midodrine should be held if the resident's systolic blood pressure (SBP) was greater than 120 mmHg. However, review of the medication administration records showed that the resident received 47 doses of midodrine when their SBP was above this threshold, with the highest recorded blood pressure at the time of administration being 169/103 mmHg. The Director of Nursing confirmed that the hold parameters were present in the physician's order but were not reflected on the medication administration record, resulting in the medication being given contrary to the specified parameters.