Failure to Administer PRN Antihypertensive Medication as Ordered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not administering clonidine, a blood pressure medication, as ordered when the resident's blood pressure readings were within the parameters requiring its use. The resident, a male with hypertensive heart disease and heart failure, had a physician's order for clonidine to be given as needed if systolic blood pressure exceeded 150 mmHg or diastolic exceeded 100 mmHg. Record review showed that over a two-month period, there were twelve instances where the resident's blood pressure met these criteria, but clonidine was not administered. Additionally, the medication administration record indicated that clonidine was not given at all during these months, despite the resident consistently receiving another antihypertensive medication, amlodipine, as scheduled. Interviews with nursing staff and facility leadership revealed that blood pressure was typically checked only once daily, rather than every six hours as would be necessary to determine the need for as-needed clonidine administration. Staff were unclear about whether blood pressure was rechecked after an elevated reading, and there was no documentation to support that rechecks occurred. Facility policy required obtaining and recording vital signs as per physician orders and administering medications accordingly, but these procedures were not followed, resulting in the resident not receiving prescribed as-needed medication when indicated.