Failure to Follow Antihypertensive Hold Parameters
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for holding antihypertensive medications for one resident. The resident was admitted with diagnoses including an unspecified thoracic vertebra wedge compression fracture, essential hypertension, and generalized muscle weakness. The physician’s orders, dated 12/3/2025, directed that atenolol 50 mg by mouth daily be held if systolic blood pressure (SBP) was less than 110 mmHg or pulse was less than 60 bpm, and that losartan 100 mg by mouth daily be held if SBP was less than 110 mmHg. The resident’s History and Physical indicated the resident had capacity to understand and make decisions, while the MDS dated 12/5/2025 documented severely impaired cognitive skills for daily decisions and dependence on staff for toileting, showering, and dressing. Review of the Medication Administration Record for 12/2025 showed that LVN 1 documented administration of atenolol and losartan on multiple dates when the resident’s SBP was below the 110 mmHg hold parameter. Specifically, atenolol and losartan were documented as given on 12/25/2025 at 9 a.m. with a BP of 109/70 mmHg, losartan was documented as given on 12/26/2025 at 9 a.m. with BP 108/72 mmHg, on 12/27/2025 at 9 a.m. with BP 106/68 mmHg, and on 12/28/2025 at 9 a.m. with BP 109/70 mmHg, and atenolol again on 12/28/2025 at 9 a.m. with BP 109/72 mmHg. During interview, LVN 1 stated that a check mark on the MAR indicated the medication was administered and claimed he had actually held the atenolol and losartan on those dates and times but could not prove this. RN 1 and the DON both stated that LVN 1 should have followed the physician’s orders and held the medications when SBP was below 110 mmHg, and the facility’s medication administration policy required medications to be administered as prescribed, including verification of vital signs when necessary.
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