F0684

E

Failure to Follow Antihypertensive Medication Parameters for Two Residents

Shippensburg, Pennsylvania Survey Completed on 02-02-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to administer antihypertensive medications in accordance with physician orders and facility policy for two residents. Facility policy required medications to be administered according to orders, including time frames and verification of vital signs when necessary. For a resident with Parkinson’s disease and hypertension, multiple physician orders for Lisinopril 2.5 mg included specific systolic blood pressure (SBP) parameters for administration and PRN use. Review of the August and September 2025 and January 2026 MARs showed that Lisinopril was administered when SBP values were below or outside the ordered parameters on numerous dates, including SBPs such as 118, 119, 122, 123, 131, 132, 137, 138, 139, and 140 when the order required higher SBP thresholds. Additionally, the PRN Lisinopril ordered for SBP greater than 140 was not administered on multiple dates when SBP readings met or exceeded that threshold, including readings of 140, 141, 143, 144, 149, 151, 153, 154, 156, 161, and 170.

For a second resident with hypertension and heart failure, physician orders specified hydralazine HCL 20 mg twice daily with instructions to hold the medication for blood pressure less than 100/60. Review of the January 2026 MAR revealed that hydralazine was administered despite blood pressure readings below the ordered hold parameters, including 98/50, 96/57, and 84/51. During an interview, the DON stated that the facility’s expectation was that medications be administered in accordance with physician orders and ordered parameters. The survey findings concluded that the facility did not ensure care and services were provided in accordance with professional standards of practice and physician-ordered parameters for these two residents.