Failure to Administer Blood Pressure Medication per Physician Parameters
Penalty
Summary
The facility failed to ensure that blood pressure medication was administered according to physician-ordered parameters for one resident. The resident had multiple diagnoses, including orthostatic hypotension and hypertension, and was prescribed Midodrine with instructions to hold the medication if systolic blood pressure exceeded 140. Review of the Medication Administration Record (MAR) showed that the medication was marked as administered on several occasions when the resident's systolic blood pressure was above the specified threshold. On some dates, there were no corresponding medication administration notes to explain the deviation, and on other dates, progress notes indicated the medication was held, but the MAR still reflected it as administered. Interviews with nursing staff and the Director of Nursing confirmed that the medication should not have been given when the systolic blood pressure was above 140, and that the MAR documentation did not always accurately reflect whether the medication was administered or held. The facility's policy required medications to be administered in accordance with prescriber orders and for staff to document administration in the electronic MAR after each dose. The failure to follow these procedures resulted in the administration of medication outside of prescribed parameters and inconsistent documentation.