Failure to Follow Medication Hold Parameters for Blood Pressure Medication
Penalty
Summary
Facility staff failed to ensure that a resident was free from significant medication errors by not adhering to physician orders regarding the administration of Midodrine, a medication used to treat low blood pressure. The resident, who had multiple diagnoses including interstitial pulmonary disease, generalized anxiety disorder, major depressive disorder, unspecified dementia, dysphagia, Barrett's esophagus, and generalized weakness, was assessed as having moderate cognitive impairment. Physician orders specified that Midodrine should be held if the resident's systolic blood pressure exceeded certain thresholds, initially greater than 130 mmHg and later changed to greater than 120 mmHg. A review of the Medication Administration Record (MAR) for September and October showed that staff administered Midodrine on several occasions when the resident's systolic blood pressure was above the ordered parameters. Specifically, the medication was given when the resident's systolic blood pressure was recorded as 139, 132, 145, and 131 mmHg, all above the hold parameters set by the physician. Interviews with nursing staff and the Director of Nursing confirmed the expectation that physician orders should be followed exactly as prescribed, but the records demonstrated that this did not occur.