F0684

D

Failure to Follow Blood Pressure Parameters for Midodrine Administration

Richmond, Virginia Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

Facility staff failed to administer Midodrine according to physician orders for one resident with hypotension related to end stage renal disease and dependence on dialysis. The physician’s order, dated 11/4/2025, specified Midodrine 10 mg via PEG tube every 8 hours to be given only when the resident’s systolic blood pressure (SBP) was under 100 mmHg. The comprehensive care plan documented the resident’s hypotension and directed staff to give medications as ordered and monitor vital signs as ordered and as clinically indicated. The facility’s medication administration policy required staff to validate physician-ordered parameters prior to medication administration.

Despite these orders and policies, the January 2026 MAR showed that Midodrine was administered on multiple occasions when the resident’s SBP was above 100 mmHg. Specifically, the drug was given when blood pressures were recorded as 126/80, 122/76, 126/86, 148/80, 125/78, and 117/83. During an interview, an LPN stated that when a medication has blood pressure parameters, the nurse should take the blood pressure and then administer or hold the medication based on the physician’s order, and acknowledged that the Midodrine should not have been administered under the documented blood pressure readings. Administrative staff were informed of these findings, and no additional information was provided prior to survey exit.