HospitalInspections.org

Based on record review and interview, the facility failed to ensure blood pressure medications were administered per physician orders. 3 (#1, 2, and 3) of 10 patients did not received PRN (as needed) blood pressure medications when their SBPs (systolic blood pressures) were found to be out of prescribed range.

Findings include:

Review of patient #1's medical record revealed the following:
-Patient #1 was admitted on 9/17/13;
-There was a physician order for clonidine 0.1mg by mouth for SBP>170 written on 9/17/13;
-On 9/18 at 7:45am, the patient's SBP was 171 and no clonidine was given;
-On 9/18 at 4:20pm, the patient's SBP was 171 and no clonidine was given;
-On 9/19 at 7:20am, the patient's SBP was 173 and no clonidine was given;
-There was no evidence alternative medications were administered in response to these readings;
-There was no evidence the physician was contacted regarding these SBP readings.

Review of patient #2's medical record revealed the following:
-Patient #2 was admitted on 3/18/14;
-There was a physician order for labetalol 10mg every 2 hours for SBP>140 written on 3/18/14;
-On 3/20 at 7:00am, the patient's SBP was 144, but there was a 2.5 hour delay in giving the labetalol (given at 9:30am);
-On 3/20 at 4:00pm, the patient's SBP was 146 and no labetalol was given;
-On 3/22 at 4:30am, the patient's SBP was 148 and no labetalol was given;
-On 3/22 at 8:00am, the patient's SBP was 148 and no labetalol was given;
-On 3/22 at 12:00noon, the patient's SBP was 149 and no labetalol was given;
-There was no evidence alternative medications were administered in response to these readings;
-There was no evidence the physician was contacted regarding these SBP readings.

Review of patient #3's medical record revealed the following:
-Patient #3 was admitted on 3/10/14;
-There was a physician order for hydralazine 10mg IV every 2 hours for SBP>150 written on 3/10/14 at 6:00am;
-On 3/10 at 7:45am, the patient's SBP was 155 and no hydralazine was given;
-On 3/10 at 10:30am, the patient's SBP was 157 and no hydralazine was given;
-On 3/10 at 11:00am, the patient's SBP was 160 and no hydralazine was given;
-On 3/10 at 11:15am, the patient's SBP was 171 and no hydralazine was given;
-On 3/10 at 12:00noon, the patient's SBP was 159 and no hydralazine was given;
-On 3/10 at 2:30pm, the patient's SBP was 161 and no hydralazine was given;
-On 3/10 at 3:00pm, the patient's SBP was 159 and no hydralazine was given;
-On 3/10 at 3:30pm, the patient's SBP was 156 and no hydralazine was given;
-On 3/10 at 4:00pm, the patient's SBP was 176 and no hydralazine was given;
-On 3/10 at 4:30pm, the patient's SBP was 164 and no hydralazine was given;
-On 3/10 at 5:00pm, the patient's SBP was 180 and no hydralazine was given;
-On 3/10 at 5:30pm, the patient's SBP was 176 and no hydralazine was given;
-On 3/10 at 6:00pm, the patient's SBP was 181 and no hydralazine was given;
-On 3/10 at 6:15pm, the patient's SBP was 158 and no hydralazine was given;
-On 3/11 at 5:00am, the patient's SBP was 171 and no hydralazine was given;
-On 3/11 at 6:00am, the patient's SBP was 167 and no hydralazine was given;
-On 3/11 at 7:00am, the patient's SBP was 170 and no hydralazine was given;
-On 3/11 at 1:00pm, the patient's SBP was 167 and no hydralazine was given;
-On 3/11 at 2:00pm, the patient's SBP was 176 and no hydralazine was given;
-On 3/11 at 5:00pm, the patient's SBP was 173 and no hydralazine was given;
-On 3/11 at 6:00pm, the patient's SBP was 151 and no hydralazine was given;
-On 3/11 at 8:00pm, the patient's SBP was 162 and no hydralazine was given;
-On 3/11 at 11:01pm, the patient's SBP was 173 and no hydralazine was given;
-On 3/12 at 2:04am, the patient's SBP was 162 and no hydralazine was given;
-On 3/12 at 3:00am, the patient's SBP was 161 and no hydralazine was given;
-There was no evidence alternative medications were administered in response to these readings;
-There was no evidence the physician was contacted regarding these SBP readings.

Staff #1 reviewed the medical records for patients #1, 2, and 3. During an interview on 4/30/14 at 2:40pm, staff #1 confirmed these findings.