Blood Pressure Medication Administered Outside Ordered Parameters and Not Reported
Penalty
Summary
A registered nurse administered Losartan Potassium 25 mg to a male resident with severe cognitive impairment, despite the physician's order to hold the medication if the systolic blood pressure (SBP) was less than 120 or diastolic blood pressure (DBP) was less than 70. At the time of administration, the resident's blood pressure was 110/76, which was outside the ordered parameters. The nurse did not notify the Director of Nursing (DON) or the physician about the medication error as required by facility policy. Following the administration, the resident's family member observed changes in the resident's condition, including altered breathing, pallor, and increased weakness, and requested that the nurse check his vital signs. The nurse found the resident's blood pressure to be 98/50. Subsequent interviews confirmed that neither the DON nor the physician was informed of the medication error, and the facility's policy requiring immediate reporting of such errors was not followed. The resident had multiple comorbidities, including a history of heart disease, hypokalemia, and congestive heart failure.