Failure to Follow BP Hold Parameters for Heart Failure Medications
Penalty
Summary
Surveyors identified a deficiency in medication management when nursing staff failed to follow physician-ordered parameters for heart failure medications for Resident #1. The resident was admitted with diagnoses including unspecified systolic (congestive) heart failure, atherosclerotic heart disease of native coronary artery without angina pectoris, unspecified cardiac arrhythmia, other cardiomyopathies, and the presence of an automatic implantable cardiac defibrillator. A 5-day MDS showed the resident was cognitively intact with a BIMS score of 14/15 and required substantial assistance with toileting/transfers, as well as dialysis and IV access. The care plan included a focus on altered cardiovascular status related to hypertension, coronary artery disease, heart failure, and history of pulmonary embolism, with an intervention to monitor vital signs as ordered and notify the MD of significant abnormalities. Review of physician orders and the January MAR revealed multiple instances where ordered blood pressure (BP) hold parameters were not followed. For Carvedilol 6.25 mg twice daily, ordered to be held for SBP less than 115 and/or heart rate less than 60, staff administered doses when the resident’s SBP was below 115 on four occasions (114/58, 102/72, 110/60, and 112/70). For Isosorbide Dinitrate 20 mg three times daily, ordered to be held for SBP less than 115, staff administered the medication five times when SBP was below 115 (110/71, 114/58, 102/72, 110/60, and 114/72), and once under a revised schedule (three times daily on specified days) when SBP was 112/70. On one occasion, a BP of 92/54 was documented and the medication was held. During interview, the DON confirmed that these administrations were outside the physician-ordered parameters and stated her expectation that licensed nurses adhere to the six rights of medication administration and follow physician orders, consistent with the facility’s oral medication administration policy requiring review of physician orders and verification of the MAR/EMAR when there are uncertainties.
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