F0755

D

Failure to Follow Midodrine Hold Parameters for Hypotensive Resident

Santa Ana, California Survey Completed on 01-16-2026

Penalty

No penalty information released

Summary

The facility failed to provide pharmaceutical services in accordance with physician orders and its own medication administration policy for one resident. Facility policy revised 12/19/22 required that medications be administered by licensed nurses or other legally authorized staff as ordered by the physician, including obtaining and recording vital signs when applicable and holding medications when vital signs were outside prescribed parameters. Resident 2, who had a history of congestive heart failure and hypotension and lacked capacity to make medical decisions, had a physician’s order dated 8/20/25 for Midodrine HCl 10 mg via GT every eight hours for hypotension, with instructions to hold the medication if systolic blood pressure (SBP) was greater than 100 mmHg. The resident’s care plan for hypotension dated 9/4/25 directed staff to administer Midodrine for hypotension, monitor vital signs, and notify the MD of significant abnormalities.

Review of the January 2026 MAR showed that staff administered Midodrine multiple times when the resident’s SBP exceeded the ordered hold parameter of 100 mmHg. Specifically, the medication was given when SBP readings were 106/61, 156/78, 102/60, 112/71, 139/70, 139/68, 124/76, 136/70, 127/64, 116/68, 106/66, 138/68, 126/72, and 108/66 mmHg on various dates and times in January. During an interview and concurrent record review on 1/16/26, an RN confirmed the Midodrine order, verified that the medication had been administered despite SBP readings above 100 mmHg, and stated that the medication should not have been given on those occasions and that this could affect the resident’s health. The administrator and nursing consultant were informed of and acknowledged these findings.