Failure to Hold Antihypertensive Medication per Physician Order
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with physician orders for one resident by not holding amlodipine when the resident's systolic blood pressure (SBP) was below the prescribed threshold. Specifically, the physician order directed that amlodipine be held if the SBP was less than 110 mmHg. Despite this, the medication was administered when the resident's SBP was recorded at 105/76 mmHg. This action was confirmed through review of the Medication Administration Record and interviews with the Assistant Director of Nursing and the Director of Nursing, both of whom acknowledged that the medication should have been withheld according to the order. The resident involved had multiple diagnoses, including sepsis, lobar pneumonia, and essential hypertension, and was dependent on staff for all activities of daily living with severely impaired cognitive skills. The facility's policy required that medications be administered as prescribed and that vital signs be checked and verified prior to administration when necessary. The failure to follow the physician's order and facility policy resulted in the administration of a blood pressure-lowering medication despite a low SBP reading.