Failure to Follow Medication Administration Parameters for Hypotension Medication
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of Midodrine, a medication prescribed for hypotension. According to physician orders, Midodrine was to be administered only if the resident's blood pressure (BP) was below 100/60 mmHg, and a BP reading was required prior to each dose. However, the medication administration records revealed that the resident received Midodrine multiple times without a BP being taken beforehand, and on several occasions, the medication was administered when the resident's BP was outside the prescribed parameters. There were also instances where the medication was not given when it should have been, according to the physician's orders. The resident involved was over 65 years old, had diagnoses including unspecified cirrhosis of the liver, muscle weakness, acute respiratory failure with hypoxia, and chronic hepatic failure, and was cognitively intact. The resident required significant assistance with activities of daily living and had a goal to discharge into the community. The medication errors occurred over several days, with the medication being given when the BP was above the threshold or withheld when it should have been administered, as documented in the medication administration records. Interviews with staff confirmed that the required BP checks were not consistently performed prior to administering the medication, and that the parameters for administration were not always followed. Nursing staff acknowledged confusion regarding the medication parameters and the necessity of BP measurement before administration. The facility's policy required medications to be administered as prescribed, including adherence to any parameters and documentation of medication errors, but these procedures were not followed in this case.