Failure to Follow Antihypertensive Hold Parameters Resulting in Significant Med Error
Penalty
Summary
Surveyors identified a deficiency related to medication administration when nursing staff failed to follow a physician’s order for an antihypertensive medication for one resident. The physician’s order, dated 10/24/25, directed that Losartan 25 mg, 0.5 tablet by mouth once daily for hypertension, be held and the MD notified if the resident’s systolic BP was less than 110, diastolic BP less than 60, or pulse less than 60. Review of the February 2026 MAR showed that staff administered 0.5 tablet of Losartan on 02/02/26, 02/07/26, 02/15/26, 02/21/26, and 02/25/26 despite documented blood pressures that were outside the ordered parameters on those dates, including readings of 108/60, 108/72, 100/65, 107/72, and 103/61, respectively. During interview, the DON confirmed that the resident received blood pressure medication outside the prescribed parameters and characterized this as a significant medication error, stating that nurses were expected to follow the order, hold the medication, and call the physician when parameters were not met.
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