WAYLAND, MI - State inspectors cited The Laurels of Sandy Creek for administering blood pressure medication to a resident outside prescribed parameters, potentially putting the patient at risk for serious cardiovascular complications.
Medication Safety Protocols Violated
During a May 2025 inspection, investigators found that nursing staff at The Laurels of Sandy Creek repeatedly administered Lotrel, a blood pressure medication, to a resident with hypertension despite the patient's blood pressure readings falling below the safe threshold specified in physician orders.
The resident's medication order specifically stated that Lotrel should be withheld if systolic blood pressure dropped below 110 mmHg or heart rate fell below 60 beats per minute. However, pharmacy records and medication administration logs revealed that staff gave the medication on multiple occasions when the resident's systolic blood pressure was below this safety parameter.
Documentation shows the medication was administered inappropriately on March 3, March 4, March 15, March 19, May 9, and May 11, 2025. Licensed Practical Nurse G was responsible for most of these administrations, according to the facility's medication administration records.
Pharmacy Warnings Ignored
The facility's own consulting pharmacist identified the problem in March 2025 and issued a formal recommendation warning about the medication errors. The pharmacy consultation report dated March 6, 2025, specifically noted that Lotrel "was administered outside of the parameters for which it was ordered" and recommended that staff be reminded about the importance of following medication parameters.
Director of Nursing B signed the pharmacist's recommendation on March 18, 2025, acknowledging receipt of the safety concern. However, when interviewed by state inspectors, the nursing director stated she did not recall the pharmacy recommendation and confirmed that no follow-up education had been provided to nursing staff about proper medication administration protocols.
Even more concerning, the medication errors continued after the pharmacy warning was issued and acknowledged by facility leadership. Records show inappropriate administrations occurred on March 19, May 9, and May 11 - all after the nursing director had signed the pharmacist's safety recommendation.
Medical Risks of Blood Pressure Medication Errors
Administering blood pressure medications when readings are already low can have serious medical consequences. Lotrel combines two active ingredients - amlodipine besylate and benazepril HCl - both designed to lower blood pressure through different mechanisms.
When given to patients with already low blood pressure, these medications can cause dangerous hypotension, potentially leading to dizziness, falls, fainting, and inadequate blood flow to vital organs. In elderly nursing home residents, who are already at higher risk for falls and cardiovascular complications, such medication errors can result in fractures, head injuries, or cardiovascular events.
The hold parameters in the physician's order - systolic blood pressure below 110 mmHg or heart rate below 60 beats per minute - serve as important safety guardrails. These parameters are established because further lowering blood pressure or heart rate beyond these thresholds could compromise the patient's cardiovascular stability.
Professional Standards and Best Practices
Healthcare facilities are required to administer medications according to established protocols that prioritize patient safety. The facility's own policy, dated October 2023, states that "resident medications are administered in an accurate, safe, timely, and sanitary manner" and that "medications are administered in accordance with written orders of the attending physician."
Standard nursing practice requires staff to assess vital signs before administering cardiovascular medications and to understand when medications should be held based on specific clinical parameters. This assessment process is fundamental to safe medication administration and helps prevent adverse drug events.
When pharmacy consultants identify medication errors and provide formal recommendations, healthcare facilities are expected to implement immediate corrective actions, including staff education and system improvements to prevent recurrence. The failure to act on the pharmacist's March 2025 warning represents a significant breakdown in the facility's quality assurance processes.
Systemic Concerns About Medication Management
The inspection findings suggest broader issues with the facility's medication management systems. The fact that multiple medication errors occurred over a three-month period, continued after pharmacy intervention, and involved different nursing staff members indicates potential systemic problems rather than isolated incidents.
Proper medication administration requires multiple safety checks, including verification of physician orders, assessment of current vital signs, and documentation of administration decisions. The repeated errors suggest these standard protocols may not be consistently followed at the facility.
The inability of facility leadership to recall important pharmacy recommendations and the lack of follow-up staff education raise questions about the effectiveness of the facility's quality assurance and staff training programs.
Additional Issues Identified
The inspection focused specifically on medication administration errors related to blood pressure medications. The violation was classified as having the potential for minimal harm, though the cumulative effect of repeated errors over time could have resulted in more serious consequences for the affected resident.
State inspectors were unable to interview the licensed practical nurse primarily responsible for the medication administrations, as the staff member was not available during the survey period. This limited the investigators' ability to fully understand the circumstances surrounding the medication errors and whether additional training or oversight issues contributed to the violations.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Laurels of Sandy Creek (the) from 2025-05-21 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.