Medication Administered Outside Ordered Blood Pressure Parameters
Penalty
Summary
The deficiency involves the facility’s failure to administer medication in accordance with a physician’s order and the facility’s own medication administration policy for one resident. The facility policy titled “Administering Medications,” revised April 2020, requires that medications be administered in accordance with prescriber orders, including any required time frame. The resident had a physician’s order dated November 29, 2024, for midodrine 5 mg by mouth twice daily for orthostatic hypotension, with a specific hold parameter to not administer the medication if the systolic blood pressure (SBP) was greater than 130. Review of the January 2026 MAR showed that the resident received midodrine 5 mg on ten occasions when the SBP exceeded the ordered hold parameter. The MAR documented that midodrine was administered despite SBP readings above 130 on multiple dates and times in January, with recorded SBPs of 131, 132, 133, 134, and 138 at the time of administration. A medication regimen review dated February 6, 2026, noted that the resident was given midodrine outside the hold parameters on several dates in January. During an interview, the resident reported not being aware that the medication had been given outside the prescribed hold parameters. In a separate interview, the Nursing Home Administrator confirmed that staff administered midodrine 5 mg outside of the prescribed hold parameters, constituting noncompliance with the physician’s order and the facility’s medication administration policy.
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