Failure to Follow Blood Pressure Parameters for Midodrine Administration
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when nursing staff did not follow ordered blood pressure parameters for administering a prescribed medication. A resident with liver failure who was not a transplant candidate, and who had complications including hepatorenal syndrome, metabolic encephalopathy, and portal hypertension, had a provider order for midodrine to be given three times daily for portal hypertension, with instructions to hold the medication if the systolic blood pressure exceeded 120 mm Hg. Review of the resident’s December 2025 MAR showed that on ten days during the month, the resident’s systolic blood pressure was above 120 mm Hg, yet midodrine was documented as administered. An LPN who gave several of these doses confirmed that a check mark on the MAR indicated the medication was given, and the DON stated that nurses were expected to follow medication parameters when administering medications. The facility’s written Medication Administration – General Guidelines, dated November 2021, required that medications be administered in accordance with the prescriber’s written orders, but the documented administration of midodrine despite blood pressure readings above the ordered threshold on multiple days demonstrated noncompliance with these guidelines and the provider’s parameters.
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