Failure to Administer PRN Antihypertensive Medication as Ordered
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors related to the administration of Clonidine, an antihypertensive medication. For one resident, a female with a diagnosis of essential primary hypertension and an intact cognitive status, the physician's order specified that Clonidine 0.1 mg should be administered by mouth every 8 hours as needed for a systolic blood pressure greater than 170 or a diastolic greater than 100. On a specific date, her blood pressure was recorded as 172/103, but the as-needed Clonidine was not administered. The nurse responsible did not recall the order or the elevated blood pressure, and could not provide a reason for not administering the medication, suggesting possible distraction or documentation error. The resident did not recall experiencing symptoms of high blood pressure at that time. A second resident, a male with diagnoses including acute chronic kidney failure, hypertension, congestive heart failure, and type 2 diabetes, also had a physician's order for Clonidine 0.1 mg by mouth every 6 hours as needed for a systolic greater than 160 or diastolic greater than 100. Blood pressure logs showed two readings of 164/66, but the medication was not administered on those days, and the medication administration record reflected that Clonidine was not given at all during the month. Interviews with staff revealed inconsistencies in documentation practices, with one LVN admitting to sometimes not updating or recording blood pressures before medication administration, and a medication aide stating she always took and documented blood pressures but could not explain the missing documentation. The facility's policy required medications to be administered as prescribed and documented on the medication administration record. However, interviews with nursing leadership confirmed that there was no current process for auditing blood pressure documentation, and that staff should have rechecked elevated blood pressures and administered PRN antihypertensive medications as ordered. The lack of adherence to physician orders and documentation requirements led to significant medication errors for both residents.