Failure to Follow Antihypertensive Medication Hold Parameters
Penalty
Summary
The facility failed to ensure that nursing services met professional standards of quality when staff did not follow a physician’s medication order for one resident. The resident had a physician’s order dated 10/24/25 for Losartan 25 mg, to give half a tablet by mouth once daily for hypertension, with instructions to notify the physician and hold the medication if the systolic blood pressure was less than 110, diastolic blood pressure was less than 60, or pulse was less than 60. During a medication administration observation on 02/25/26 at 8:54 a.m., an LPN obtained a blood pressure reading of 103/61 and proceeded to administer the Losartan despite the order to hold the medication when systolic blood pressure was below 110. In a subsequent interview on 02/26/26 at 3:45 p.m., the DON stated that staff administering medications are expected to follow physician orders as written and that this situation did not meet her expectations for medication administration. This deficient practice was cited as a failure to provide quality care that meets professional standards for the resident when staff did not adhere to the prescribed parameters for administering antihypertensive medication.
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