Failure to Follow Physician's Order for Blood Pressure Parameters in Medication Administration
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) administered sacubitril-valsartan to a resident despite a physician's order to hold the medication if the resident's systolic blood pressure (SBP) was below 110 mmHg. On the date in question, the resident's blood pressure was recorded at 109/77 mmHg, yet the medication was still given. The resident had a history of multiple rib fractures, falls, and hypertensive heart disease with heart failure. The medication order specifically instructed staff to withhold sacubitril-valsartan for SBP less than 110 mmHg or heart rate less than 60 beats per minute. Record reviews confirmed that the medication was administered contrary to the physician's order, and this was acknowledged by both the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) during interviews. Facility policy required medications to be administered as prescribed, including verification of vital signs when necessary. Documentation in the Medication Administration Record (MAR) and progress notes indicated that the medication was given despite the resident's blood pressure being below the specified threshold.