Failure to Hold Antihypertensive Medication for Low Heart Rate
Penalty
Summary
A significant medication error occurred when a resident with a history of essential hypertension and a moderate cognitive impairment was administered nifedipine extended release 90 mg, a blood pressure medication, despite her heart rate being below the physician-ordered parameter. The resident's medication order specified that nifedipine should be held if systolic blood pressure was less than 100 or heart rate was less than 60, and the nurse should be notified. On the date in question, the resident's heart rate was recorded at 56, but the medication was still administered by an LVN. Interviews with the LVN and the Director of Nursing (DON) confirmed that the facility's policy and the physician's order required the medication to be held and the nurse or physician to be notified if vital signs were outside the specified parameters. There was no documentation that the LVN consulted with a nurse or physician before administering the medication. The facility's policy on medication administration also required holding medications for vital signs outside prescribed parameters, which was not followed in this instance.