Failure to Administer Blood Pressure Medications per Physician Orders
Penalty
Summary
The provider failed to ensure that blood pressure medications were administered according to physician orders for a resident with diagnoses of type 2 diabetes, orthostatic hypotension, and weakness. Upon admission, the resident had specific orders for Midodrine and Fludrocortisone, both with hold parameters based on systolic blood pressure (SBP) readings. Review of the Medication Administration Record (MAR) revealed that Midodrine was administered six times when the resident's SBP was above the ordered threshold, and was not given five times when the SBP was low and the medication should have been administered. Fludrocortisone was also administered twice when the SBP was above the hold parameter. In addition, low blood pressures were not rechecked until the following day when Midodrine was held, contrary to expectations. Interviews with the Director of Nursing (DON) and Certified Medication Aides (CMAs) confirmed that the staff responsible for administering the medications did not consistently follow the blood pressure hold parameters. The DON acknowledged that the facility's policy required blood pressure to be checked prior to administration and that the physician should be notified if readings were out of parameters. The CMAs involved were not aware they had administered medications outside of the prescribed parameters and were unfamiliar with the facility's Blood Pressure Parameter Policy and notification requirements. Review of job descriptions and facility policies indicated that CMAs and RNs were responsible for observing and reporting symptoms, taking and recording vital signs, and notifying the charge nurse of medication errors. The facility's policies also required that medication errors be reported, the physician and DON notified, and the resident monitored for 24 hours following an error. Despite these policies, the required procedures were not followed, resulting in multiple medication administration errors for the resident.