Failure to Follow BP and Pulse Parameters for Cardiac Medications
Penalty
Summary
Nursing staff failed to follow physician-ordered blood pressure parameters for administration of Midodrine for one resident. The resident had been deemed incapable of making all medical decisions by two physicians and had a physician’s order dated 01/16/26 for Midodrine 10 mg orally three times a day, to be given only when the systolic blood pressure (SBP) was less than 100 mmHg and to be held when SBP was greater than 100. Review of the January 2026 MAR showed that staff administered Midodrine despite SBP readings above the ordered threshold, including doses given when SBP was documented as 102/57, 108/62, and 101/60. Nursing staff also failed to follow physician-ordered blood pressure and pulse parameters for administration of Amiodarone and Metoprolol for another resident with diagnoses including end stage renal disease on hemodialysis, difficulty walking, osteomyelitis, and atrial fibrillation, who had been deemed capable of making all medical decisions. A physician’s order for Amiodarone 200 mg orally every 12 hours directed staff to hold the medication if SBP was less than 110 or heart rate was less than 60, yet MAR review showed multiple doses given when SBP was below 110 and/or pulse was below 60. A separate order for Metoprolol 25 mg orally twice daily directed staff to hold the medication if SBP was less than 100 or heart rate was less than 60, but MAR review again showed multiple administrations when SBP and/or pulse were below the ordered hold parameters, including an instance with SBP 81/40. These findings were identified through review of closed and active clinical records and MARs during a complaint survey and shared with facility leadership at exit.
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