Failure to Follow Blood Pressure Parameters for Midodrine Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was kept free from significant medication errors when nursing staff did not administer a prescribed blood pressure medication according to physician-ordered parameters. Record review showed that the resident, an individual over 70 years old with orthostatic hypotension, unspecified dementia with behavioral disturbances, chronic kidney disease, hypomagnesemia, and osteoarthritis, had an order for midodrine 10 mg by mouth twice daily, later increased to three times daily, with instructions to hold the dose if the systolic blood pressure (SBP) was greater than 100 mmHg. Despite this clear order, the medication administration record documented that midodrine was administered 49 times when the resident’s SBP was outside the ordered parameters. The resident’s medical record indicated that the midodrine order with SBP parameters was in place from August through at least early September, and the medication administration record from 8/12/25 to 9/10/25 showed repeated administrations that did not comply with the hold parameter. These administrations occurred even when the documented SBP exceeded the threshold at which the medication was to be withheld. The facility’s own Medication Administration Guidelines policy required that medications be administered as prescribed, that nurses review and confirm orders on the MAR, obtain and record vital signs as necessary prior to administration, and clarify any questionable orders with the prescriber or pharmacy before giving the medication. Nonetheless, the documented practice for this resident did not align with those requirements. Interviews with facility staff further confirmed that the problem was systemic and involved multiple nurses not following physician orders for medication parameters. The regional corporate nurse stated that an audit of the resident’s electronic medical record revealed that nursing staff had failed to hold midodrine 49 times when the SBP was over 100 mmHg. The medical director reported that there was a systemic problem in the facility with following physician orders for medication parameters and stated that he expected nursing staff to follow those orders. The NHA also acknowledged a systemic problem with nurses following physician orders related to medication administration and adherence to blood pressure parameters. Nursing staff interviews referenced subsequent training on medication parameters, indicating that prior to that training, nurses had not consistently followed the ordered blood pressure parameters for midodrine, which led to the cited deficiency.
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