F0658

E

Failure to Follow BP Medication Parameters and Document Withheld Doses

Gallup, New Mexico Survey Completed on 01-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that services met professional standards of quality by not following physician orders for blood pressure medications for two residents. For one resident, a physician’s order dated 07/16/25 directed that lisinopril be held if the systolic blood pressure was less than 110 mmHg. Review of the Medication Administration Record (MAR) from 01/01/26 to 01/21/26 showed that on 01/05/26, staff administered lisinopril despite a documented systolic blood pressure of 105 mmHg, which was below the ordered hold parameter.

For the second resident, a physician’s order dated 11/20/25 specified that carvedilol for hypertension be held only if the systolic blood pressure was less than 110 mmHg or the heart rate was less than 60 beats per minute. The MAR for 01/01/26 to 01/21/26 showed that on 01/01/26, a dose of carvedilol was not administered and was marked “see progress note,” even though the recorded systolic blood pressure was 118 mmHg and heart rate was 70 beats per minute, both within parameters; the corresponding progress notes from 01/01/26 to 01/02/26 contained no documentation explaining the withheld dose. On 01/16/26, the evening dose of carvedilol was again not administered and referenced a nurse’s note, while the MAR documented a systolic blood pressure of 156 mmHg and heart rate of 60 beats per minute, which were within the ordered parameters, and nursing notes from 01/16/26 to 01/17/26 did not document a reason for withholding the medication. During an interview, the DON confirmed that vital signs are expected to be documented in the electronic MAR and that medications should be administered or held according to the provider’s parameters, and acknowledged that staff did not follow the orders in these instances.