F0684

E

Failure to Follow Antihypertensive Hold Parameters and Vital Sign Orders

Orono, Maine Survey Completed on 01-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow physician orders for multiple antihypertensive medications for one resident, specifically by not checking and documenting required vital signs and by administering medications outside of ordered blood pressure parameters and time frames. For Carvedilol, ordered twice daily with instructions to hold the dose if systolic blood pressure (SBP) was less than 110 or heart rate was less than 60, the record review for 12/10/25–12/23/25 showed that blood pressure and pulse were not documented on the MAR. During this period, the vital signs record showed multiple SBP readings below 110 (including 90, 95, 98, 105, 103, 104, 86, and 85) at times corresponding to medication administration, yet the MAR indicated the medication was given. On several dates there was no documented SBP in the ordered administration windows, but the MAR still showed that Carvedilol was administered.

For Diltiazem, ordered once daily between 7 a.m. and 12 p.m. with instructions to hold if SBP was less than 110 or heart rate less than 60, the facility again did not document blood pressure and pulse on the MAR between 12/18/25–12/23/25. The vital signs record showed SBP values of 105, 103, and 86 during this period, all below the ordered SBP hold parameter of 110, yet the MAR documented that Diltiazem was given on those days. On other days within the same period, there was no documented SBP in the ordered administration window, but the MAR still reflected that the medication was administered.

For Enalapril, ordered once daily between 4 p.m. and 7 p.m. with the same hold parameters (SBP less than 110 or heart rate less than 60), the MAR from 12/10/25–12/23/25 lacked blood pressure and pulse documentation. The vital signs record showed SBP readings below 110 (including 90, 95, 109, 90, 104, and 85) at or near the relevant times, yet the MAR indicated the medication was given. Some SBP readings were documented outside the ordered time window, and on several days there was no SBP documented in the 4 p.m.–7 p.m. window, but the MAR still showed administration. Similarly, for Spironolactone, ordered once daily between 7 a.m. and 12 p.m. with the same hold parameters, there was no blood pressure or pulse documented on the MAR between 12/18/25–12/23/25. During this time, the vital signs record showed SBP readings of 105, 103, and 86, all below the ordered threshold, or no SBP documented in the ordered time window, yet the MAR consistently indicated that Spironolactone was administered.