Failure to Administer Blood Pressure Medication Within Prescribed Parameters
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically in the administration of Midodrine, a medication used to treat hypotension. For one resident, physician orders for Midodrine were initiated without specifying blood pressure parameters, and subsequent orders included parameters to hold the medication if blood pressure exceeded certain thresholds. However, medication administration records showed that Midodrine was given without consistently recording blood pressures, and on multiple occasions, it was administered even when blood pressure readings were above the prescribed parameters. Another resident had physician orders for Midodrine with explicit instructions to hold the medication if blood pressure was greater than specified values. Despite these orders, documentation revealed that the medication was administered several times when blood pressure readings exceeded the hold parameters. The facility's consultant pharmacist had previously identified and communicated these issues, and in-service education was provided to nursing staff regarding the importance of adhering to blood pressure parameters when administering such medications. Interviews with nursing staff and facility leadership confirmed that staff were aware of the medication administration guidelines and the risks associated with improper administration. However, staff admitted to administering Midodrine outside of the prescribed parameters, sometimes due to inattention or being in a hurry. The facility's policy required verification of vital signs prior to medication administration, but this was not consistently followed, resulting in significant medication errors for the residents involved.