Failure to Follow Blood Pressure Parameters for Ordered Cardiac Medication
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s parameter order for a resident with atrial fibrillation who was prescribed Propranolol HCL 20 mg three times daily at 8:00 a.m., 12:00 p.m., and 5:00 p.m. The physician’s order, dated 10/9/25, directed that the medication be held if the resident’s systolic blood pressure (SBP) was less than 110. Review of the resident’s clinical record and medication administration records for November 2025, December 2025, and January 2026 showed that the Propranolol was administered despite SBP readings below the ordered threshold on multiple occasions. Specifically, the medication was given when the SBP was 106 at 8:00 a.m., 12:00 p.m., and 5:00 p.m. on 11/17/25; 105 at 12:00 p.m. on 12/24/25; 107 at 12:00 p.m. on 12/30/25; 109 at 5:00 p.m. on 01/06/26; and 107 at 5:00 p.m. on 01/16/26. During an interview, an RN stated that all parameters set by the physician must be followed. The facility’s Medication Administration Policy Guideline, dated 5/17/21 and provided by the Regional Nurse Consultant, stated that medications are to be administered as prescribed and in accordance with written physician orders, including parameters. The documented administration of Propranolol outside the ordered SBP parameters constituted the basis for the cited deficiency.
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