F0756

D

Consultant Pharmacist Failed to Identify and Report Antihypertensives Given Outside Hold Parameters

Wichita, Kansas Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure the consultant pharmacist identified and reported repeated administration of antihypertensive medications outside of physician‑ordered hold parameters for one resident. The resident had diagnoses of hypertension and congestive heart failure, a BIMS score of 12 indicating moderately impaired cognition, dependence on staff for ADLs, and was receiving an anticoagulant and a diuretic. Her care plan directed staff to administer medications as ordered, obtain vital signs at least daily per physician orders and as needed, and notify the physician of abnormal readings. Physician orders for isosorbide mononitrate 30 mg daily and amlodipine 10 mg daily for hypertension included explicit parameters to hold the medications if pulse was less than 50 BPM or greater than 120 BPM, or if BP was less than 120/40 or greater than 200/90 mm/Hg.

Review of the resident’s MARs showed that both antihypertensive medications were administered multiple times when vital signs were outside the ordered parameters over several consecutive months. In November, amlodipine and isosorbide mononitrate were each given outside parameters on 6 of 30 opportunities. In December, each medication was given outside parameters on 12 of 30 opportunities. In January, each was given outside parameters on 15 of 30 opportunities. In February, each was given outside parameters on 5 of 24 opportunities. Despite this pattern, the consultant pharmacist’s Medication Regimen Reviews from January 2025 to the present did not identify or report that these medications were being administered contrary to the physician‑ordered hold parameters.

Interviews confirmed that facility staff and administration expected medications to be held when BP or pulse readings were outside the ordered parameters and expected the consultant pharmacist to report when medications were given outside those parameters. A consultant stated she interpreted the physician parameters as directions to hold the medications when readings were below or above the ordered numbers and would expect the consultant pharmacist to identify and report when medications were not held appropriately. A CMA and a licensed nurse described processes for checking BP and pulse and holding medications or notifying a nurse when readings were low. The administrative nurse stated she expected anyone administering medications to hold them when readings were outside parameters and expected the consultant pharmacist to report such occurrences. The facility’s Pharmacy Services Overview documented that the consultant pharmacist oversees development of procedures related to medication administration and staff roles and responsibilities, but the consultant pharmacist’s reviews did not address the repeated administration of antihypertensives outside the ordered parameters for this resident.