Failure to Follow Blood Pressure Parameters for Midodrine Administration
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s ordered blood pressure parameters for administration of Midodrine for a resident diagnosed with hypotension. The physician’s order dated 2/6/26 directed that the resident receive Midodrine HCl 2.5 mg three times daily at 8:00 a.m., 12:00 p.m., and 4:00 p.m., with instructions to hold the medication if the resident’s systolic blood pressure was above 130. Review of the February 2026 MAR showed that the medication was administered despite systolic blood pressures above the ordered threshold on multiple occasions. Specifically, the MAR indicated that Midodrine was given on 2/07/26 at 4:00 p.m. when the resident’s systolic blood pressure was 132, and on 2/17/26 at 8:00 a.m., 12:00 p.m., and 4:00 p.m. when the systolic blood pressure was 138 at each of those times. During an interview, an RN stated that blood pressure medication should not be administered when a resident’s blood pressure is outside the parameters set by the physician. The facility’s Medication Administration policy, provided by the Regional Director of Clinical Operations, stated that medications are to be administered only as prescribed by the provider and identified the MAR as the legal documentation for medication administration, while emphasizing resident safety and resident-centered care.
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