Failure to Monitor Blood Pressure Prior to Midodrine Administration
Penalty
Summary
The facility failed to obtain and document blood pressure readings prior to administering Midodrine, as ordered by the physician, for one resident with multiple complex diagnoses including dementia, morbid obesity, end stage renal disease, type 2 diabetes mellitus, obstructive sleep apnea, hypertension, metabolic encephalopathy, and dependence on renal dialysis. The physician's order specified that Midodrine 5 mg should be administered three times daily for hypotension, but to hold the medication if the systolic blood pressure was greater than 90. Medical record review showed that for the months of September and October, and for multiple days in November, there was no documentation that blood pressures were obtained before administering Midodrine to the resident. This was confirmed during an interview with a registered nurse, who verified the absence of blood pressure documentation prior to medication administration for the specified periods. The deficiency was identified during the investigation of two complaint numbers.