Failure to Follow Midodrine Blood Pressure Parameters for Multiple Residents
Penalty
Summary
Facility staff failed to ensure residents’ drug regimens were free from unnecessary drugs by not following physician-ordered blood pressure (BP) parameters for Midodrine administration for three residents. One resident with a history of orthostatic hypotension, recent hospitalization for acute metabolic encephalopathy, infection, acute kidney injury, significant deconditioning, impaired mobility, chronic pain, nutritional deficits, and high fall risk was ordered Midodrine 5 mg, three tablets by mouth three times daily for hypotension, to be held for systolic blood pressure (SBP) greater than 120. The Medication Administration Record (MAR) showed Midodrine was administered on multiple dates when SBP readings were above 120, and on one date it was held when SBP was below 120, contrary to the order. After this resident returned from a hospital stay, the Midodrine order was changed to 10 mg three times daily with the same hold parameter, yet the MAR documented another administration when SBP exceeded 120. The DON later acknowledged awareness of these out-of-parameter administrations when they were brought to her attention. A second resident had a physician’s order for Midodrine 5 mg once daily for hypotension, to be held for SBP greater than 120, but the December and January MARs documented repeated administrations on days when SBP readings were above 120. A third resident had a physician’s order for Midodrine 5 mg three times daily for hypotension, to be held for SBP greater than 110, yet the December and January MARs showed numerous doses given when SBP exceeded 110. Additionally, on one occasion this resident’s SBP was below 110 and Midodrine was not administered, despite the order indicating it should have been given. During interview, the medical director confirmed that staff failed to follow the ordered parameters and expressed concern about Midodrine being administered outside of those parameters.
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