Charlestown Place: Blood Pressure Med Errors - IN
The resident's physician had ordered staff to hold Lisinopril if their systolic blood pressure dropped below 110. Instead, nurses administered the 10-milligram daily dose when the resident's pressure measured as low as 100.
Resident K's medical record showed a diagnosis of hypertension. Their care plan from June indicated they had altered cardiovascular status requiring medications administered as ordered by their physician. The doctor's April order was clear: give Lisinopril 10 mg each morning, but hold it if systolic blood pressure falls below 110.
Medication administration records from July and August revealed a pattern of dangerous oversights. On July 8, nurses gave the medication when the resident's systolic pressure was 100. They repeated this on July 11 with the same reading.
The violations continued throughout July. On the 23rd, staff administered Lisinopril with a systolic reading of 106. Five days later, they gave it again at 100. The next day brought another dose at 104.
August showed no improvement in medication safety. Nurses administered the blood pressure medication on August 4 when the resident's systolic pressure was 106. The following day, they gave it at 103. On August 6, they administered it at 109 — still below the physician's safety threshold.
Each administration violated the doctor's explicit instructions designed to prevent the resident's blood pressure from dropping to potentially dangerous levels.
When inspectors interviewed Registered Nurse 5 on August 12, the nurse acknowledged the basic safety protocol. If a resident's blood pressure was out of parameters, the medication should not be given, the nurse said.
The facility's own policies supported this approach. The Executive Director provided inspectors with a document titled Medication Administration that outlined requirements for obtaining and recording vital signs before giving medications. The policy stated medications would be administered in accordance with applicable state, local and federal laws, consistent with accepted standards of practice.
Yet these standards failed repeatedly with Resident K. The systematic medication errors occurred over eight separate occasions across two months, suggesting broader problems with nursing supervision and medication safety protocols.
Blood pressure medications like Lisinopril work by relaxing blood vessels and reducing the heart's workload. When given to patients with already low blood pressure, they can cause dangerous drops that may lead to dizziness, falls, fainting, or worse complications. Physicians set specific parameters to prevent these risks.
The inspection occurred in response to a complaint filed as case number 25809923.1-37. Federal regulations require nursing homes to provide appropriate treatment and care according to physician orders and resident preferences.
The violation affected few residents, according to the inspection report, but demonstrated failures in basic medication safety that could have serious consequences. Inspectors classified the harm level as minimal or potential for actual harm.
The facility's medication administration failures highlight ongoing challenges in nursing home care coordination. When staff ignore physician parameters for medication administration, they put vulnerable residents at risk for preventable complications.
Resident K's case illustrates how seemingly routine medication errors can accumulate into patterns of unsafe care. Eight separate violations over two months suggest systemic problems rather than isolated mistakes.
The inspection found that Charlestown Place failed to ensure appropriate treatment according to physician orders for this resident. The facility's own policies required proper vital sign monitoring before medication administration, yet staff repeatedly ignored both the doctor's specific instructions and their internal protocols.
For Resident K, the consequences of receiving blood pressure medication with dangerously low readings could have included serious medical complications. The repeated nature of these errors over multiple weeks demonstrates a concerning breakdown in basic nursing care standards.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Charlestown Place At New Albany from 2025-08-12 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
CHARLESTOWN PLACE AT NEW ALBANY in NEW ALBANY, IN was cited for violations during a health inspection on August 12, 2025.
The resident's physician had ordered staff to hold Lisinopril if their systolic blood pressure dropped below 110.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.