Failure to Administer Prescribed Medication per Physician Order
Penalty
Summary
The facility failed to ensure that a resident received pharmaceutical services in accordance with professional standards of practice by not administering midodrine as prescribed by the physician. The resident, who had diagnoses including Parkinson's disease and hypotension, had a physician's order for midodrine hydrochloride 10 mg by mouth three times daily, to be held only if systolic blood pressure (SBP) exceeded 150. On the date in question, the resident's blood pressure was 150/89, which was within the prescribed parameters for administration, yet the medication was not given. During interviews and record reviews, it was confirmed that the medication was withheld by an LVN who was concerned about the resident's blood pressure increasing, despite the physician's order specifying when to hold the medication. The facility's policy required medications to be administered as prescribed and in a timely manner. The omission of the medication was acknowledged by both the MDS nurse and the LVN, who stated that the medication should have been administered according to the physician's order.