Failure to Follow Physician Parameters for Antihypertensive Medications
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for blood pressure medications for two residents. One resident with hypertension and type 2 diabetes had a physician’s order, dated May 26, 2023, for daily amlodipine with instructions to hold the medication if the systolic blood pressure (SBP) was below 120 mm/Hg. Review of this resident’s MAR for October, November, and December 2025, and January and February 2026, showed that staff administered amlodipine despite SBP readings below 120 mm/Hg on multiple occasions: once in October, once in December, six times in January, and once in February. The second resident, with hypertension and multiple sclerosis, had a physician’s order dated May 15, 2025, for diltiazem three times daily, with instructions not to administer the medication if SBP was below 110 mm/Hg or if heart rate was less than 60 beats per minute. Clinical record review revealed that this resident’s heart rate was documented only twice in September 2025 and once each in January and February 2026. Despite this lack of heart rate measurements, review of the MAR for October, November, and December 2025 showed that staff administered diltiazem three times daily without measuring the resident’s heart rate as ordered. In an interview, the DON confirmed that the physician orders for both residents were not followed and that medications were administered outside the ordered parameters.
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