F0760

E

Failure to Follow Hold Parameters and Accurate Administration of Ordered Medications

Katy, Texas Survey Completed on 03-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, specifically related to blood pressure medications and an anticonvulsant medication. For one male resident with hypertension, dementia, Alzheimer’s disease, depression, hypothyroidism, urinary tract infection, and cognitive communication deficits, the physician ordered hydralazine 25 mg three times daily and telmisartan 40 mg once daily with explicit hold parameters. Hydralazine was to be held if systolic blood pressure (SBP) was less than 130 or pulse was greater than 85, and telmisartan was to be held if SBP was less than 130 or pulse was less than 60. Review of the Medication Administration Records (MARs) for February and March showed multiple instances where these medications were administered and not documented as held despite SBP and pulse readings that met the ordered hold parameters.

In February, the resident’s SBP readings were repeatedly below 130 at various administration times, and pulse readings were above 85 on several dates, yet hydralazine was not documented as held. Similarly, telmisartan was not documented as held on multiple days when SBP was below 130 and when pulse readings were below 60. In March, the same pattern continued: hydralazine and telmisartan were administered without being held even when SBP and pulse values fell within the parameters requiring the medications to be withheld. The clinical record and nurses’ notes for these months contained no documentation that the physician was notified of the consistently out-of-parameter blood pressure and pulse readings, and no documented reasons were provided for not holding the medications as ordered.

During interviews, a LVN stated that if there was an order to hold blood pressure medications within certain parameters and it was not followed, the resident’s blood pressure could get higher or lower and the resident could get sicker. She acknowledged that in this resident’s case, she did not document any physician notification and stated that in nursing, if it is not documented, it is considered not done, taking responsibility for the lack of documentation. The DON confirmed that nurses were expected to review parameters before administering blood pressure medications and acknowledged that if medications were given when readings were out of parameter, it could cause the blood pressure to be higher or lower. The DON also stated that medication reviews were generally triggered by changes in condition, such as falls, and that nurses should notify the physician when blood pressure readings were consistently outside the ordered parameters.

A second deficiency involved another resident, a female with a gastrostomy tube, GERD, aphasia following cerebrovascular disease, hemiplegia and hemiparesis, convulsions, essential hypertension, cognitive communication deficit, and other lack of coordination. This resident was NPO and received nutrition and medications via a G-tube, with orders to check tube placement and residuals and to flush the tube before and after medications. The physician’s order included Lacosamide 150 mg via PEG-tube every 12 hours to treat partial-onset seizures. During a medication administration observation, an RN checked the resident’s blood pressure, prepared and crushed three medications, diluted them with water, checked G-tube residual, and administered the medications through the G-tube. Lacosamide was ordered and initialed as given on the MAR for that morning, but the surveyor did not observe it being administered during the pass.

In a subsequent interview, the RN stated she later realized she had to get three more medications, including iron and a vitamin, and claimed she returned and gave them after passing medications on another side, but she did not recall the exact time. The DON stated that medications ordered every 12 hours should be given at 9:00 a.m. and 9:00 p.m., and that if the RN had administered the medication, she should have informed the surveyor. The DON also noted that he could not defend the administration because the surveyor did not observe the medication being given, even though it was initialed as administered on the MAR. The facility’s medication administration policy required medications to be administered safely, timely, and as prescribed, within one hour of the scheduled time, and required that the individual administering the medication initial the MAR after giving each medication before administering the next, as well as documenting and reporting medication errors.