Failure to Follow Physician-Ordered Parameters for Blood Pressure Medication
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not adhering to physician-ordered parameters for administering Clonidine, a blood pressure medication. Specifically, the medication was given nine times in January 2026 when the resident's systolic blood pressure was below the ordered threshold of 160, contrary to the physician's instructions. Documentation on the medication administration record (MAR) confirmed that the medication was administered outside the prescribed parameters, and interviews with medication aides and nursing staff acknowledged the oversight and failure to follow the order as written. The resident involved was an older female with diagnoses of hypertension urgency and essential hypertension, who was cognitively intact according to her most recent assessment. Her care plan and physician orders clearly specified the conditions under which Clonidine should be administered. Despite this, medication aides administered the drug when the resident's blood pressure readings did not meet the required criteria. Staff interviews revealed that the medication should have been withheld in these instances, and the facility's policy required medications to be given in accordance with physician orders.