Failure to Administer Ordered Antihypertensives/Diuretics and Notify Physician of Medication Hold
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors and to notify the physician when ordered medications were withheld. The resident had diagnoses of HTN and CHF and was prescribed multiple antihypertensive and diuretic medications, including valsartan 320 mg daily, metoprolol tartrate 50 mg twice daily, furosemide 40 mg daily, and hydrochlorothiazide 12.5 mg daily, all with specific parameters to notify the physician if SBP was less than 90 mm/Hg or greater than 180 mm/Hg, DBP less than 40 mm/Hg or greater than 100 mm/Hg, or pulse less than 50 or greater than 110 on two consecutive checks two hours apart. The resident’s care plan directed staff to administer medications as ordered and monitor blood pressure, holding medications per physician-set parameters. On the date in question, the Medication Administration Record documented that none of the four ordered medications were given, and the EMR notes show that the CMA recorded each medication as held per nursing judgment. According to staff interviews, the CMA obtained a blood pressure reading of approximately 111/49 mm/Hg, rechecked it with the diastolic still in the 40s, and reported this to the nurse. The nurse instructed the CMA to hold the medications based on nursing judgment and confirmed that the physician was not notified. Administrative nursing staff later stated that the nurse did not notify the physician because the blood pressure was not within the parameters requiring provider notification, despite the physician’s orders specifying when to notify. The facility’s Medication Administration Policy stated that medications shall be administered safely as ordered by the physician, but the ordered antihypertensive and diuretic medications were not administered and the physician was not contacted regarding the decision to hold them.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.