Incorrect Entry and Administration of PRN Antihypertensive Medication
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured accurate order entry and administration of medications for a resident with essential hypertension, heart failure, and atrial fibrillation. The resident, who had severe cognitive impairment with a BIMS score of 6/15, was admitted with hospital discharge paperwork indicating cloNIDine 0.1 mg to be taken by mouth twice daily as needed (PRN) for hypertension. However, the facility’s Order Summary Report listed cloNIDine HCl 0.1 mg as a scheduled medication to be given twice daily with specific hold parameters for blood pressure and pulse. The March MAR showed that cloNIDine HCl was administered on one date when the resident’s blood pressure was 142/52 and pulse 58. During interviews, the CMA who administered the medication stated she gave all prescribed blood pressure medications as ordered and was not aware of a PRN blood pressure medication or any parameters on the order. The RN who admitted the resident reported that she sent the hospital medication list to the NP for approval and then entered the approved medications into the electronic record, later learning that one medication had been entered incorrectly as scheduled instead of PRN. The NP confirmed that cloNIDine HCl should have been ordered as PRN to allow it to be held or staggered based on blood pressure and pulse readings. The DON stated that the admitting nurse should validate medication orders with the physician and acknowledged that inaccurate order entry could result in a resident having a change in condition. The facility’s medication administration policy stated that medications shall be administered as prescribed by the attending physician.
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