Antihypertensive Given Outside Ordered Parameters
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors related to administration of an antihypertensive medication outside of ordered parameters. The resident was an older male with essential hypertension and a BIMS score of 8, indicating moderate cognitive impairment. His care plan included an intervention to administer antihypertensive medication as ordered. The physician’s order for carvedilol 6.25 mg twice daily specified it should be held if blood pressure was less than 120/60 and pulse less than 60. Review of the December MAR showed that on two occasions carvedilol was administered by an LVN when the resident’s recorded blood pressures were 115/65 and 112/67, which were outside the ordered blood pressure parameters for giving the medication. During interview, the LVN confirmed she signed the MAR indicating she administered carvedilol on those dates and acknowledged she was not supposed to administer blood pressure medications outside specified parameters unless given specific instructions by a physician or nurse practitioner. She stated that administering blood pressure medications outside parameters could cause fatigue, headache, or fainting. The DON, upon review of the MAR, stated it appeared the LVN administered carvedilol despite the blood pressures being outside the stated parameters and confirmed the medication should not have been given on those days. The facility’s Medication Administration policy required staff to obtain and record vital signs when applicable or per physician orders and to hold medications when vital signs were outside the physician’s prescribed parameters, which was not followed in this case.
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