Failure to Follow Antihypertensive Parameters Leading to Fall and Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when nurses did not follow physician-ordered blood pressure parameters for multiple antihypertensive medications. The resident had hypertension, chronic kidney disease, congestive heart failure, and a history of falls, and was ordered furosemide, hydralazine, and lisinopril at 11:00 AM with specific instructions to hold each medication if systolic blood pressure or diastolic blood pressure fell below defined thresholds. Review of the Medication Administration Record showed that on several dates, including when the resident’s diastolic blood pressure was below 60 or systolic blood pressure was below 110 as specified in the orders, staff still administered one or more of these medications instead of holding them and notifying the provider. Staff interviews confirmed that the electronic system did not prevent administration outside parameters and that it was the nurse’s responsibility to review the full order and hold medications when vital signs were outside the ordered range. On one of the days when medications were administered despite a diastolic blood pressure below the ordered parameter, the resident experienced dizziness while standing at the sink, attempted to turn and sit on the bed, and fell, striking the face and later being found to have a right forehead hematoma and an acute L2 compression fracture. The resident reported ongoing back pain and described having a lot of problems with blood pressure and blood pressure medications. The resident’s representative reported concerns about overdosing with blood pressure medications since admission, stating the resident had falls, dehydration requiring fluids, and increased weakness due to mismanagement. The Director of Nursing acknowledged that administering blood pressure medications outside the ordered parameters constituted medication errors and that these errors were not identified during the investigation of the resident’s fall, and medication was not identified as a contributing factor at that time.
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