Failure to Administer Blood Pressure Medication Within Prescribed Time Parameters
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not administering a blood pressure and pulse-altering medication, Midodrine, within the prescribed time parameters as ordered by the physician. The physician's order specified that Midodrine should be given three times daily for hypotension, held if systolic blood pressure was 130 or above, and not administered after the evening meal or within four hours of bedtime. Despite these clear instructions, documentation showed that the medication was administered on multiple occasions late in the evening, well after the designated time frame following the evening meal. Record review indicated that the resident had significant medical conditions, including Type 2 diabetes, dementia with severe cognitive impairment, high blood pressure, coronary artery disease, and acute kidney failure. The resident's care plan included interventions to administer hypotension medications as ordered and to monitor for side effects and effectiveness. However, medication administration records and blood pressure logs revealed that Midodrine was given outside the prescribed parameters on several dates, with administration times ranging from approximately 8:30pm to 9:20pm, despite dinner being served at 5:00pm. Interviews with medication aides and the DON confirmed that staff were aware of the physician's orders and the importance of timely administration and accurate documentation. Both staff members acknowledged that the medication should not have been given after 6:00pm and that accurate documentation was necessary for monitoring the resident's response to the medication. The DON also noted that the facility's system did not alert staff if the medication was given late, and that audits were conducted, but the issue persisted. Facility policies required medications to be administered as ordered and documentation to be accurate and timely, but these were not followed in this case.