Failure to Follow Blood Pressure Parameters for Midodrine Administration
Penalty
Summary
Surveyors found that the facility failed to follow a physician’s ordered blood pressure parameter for administration of Midodrine for one resident. Resident K had a diagnosis that included hypotension and a physician’s order, dated 2/14/26, for Midodrine 10 mg via gastrostomy tube three times daily at 6:00 a.m., 2:00 p.m., and 10:00 p.m., with instructions to hold the medication if the systolic blood pressure (SBP) was greater than 110. Review of the February 2026 medication administration record showed that staff administered Midodrine despite SBP readings above the ordered parameter on multiple occasions: on 2/16/26 at 10:00 p.m. when SBP was 122, on 2/17/26 at 6:00 a.m. when SBP was 126, on 2/17/26 at 10:00 p.m. when SBP was 119, and on 2/19/26 at 6:00 a.m. when SBP was 119. In an interview, an LPN stated that physician’s orders should be followed, confirming that the medication should not have been given when the SBP exceeded the ordered threshold.
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