Failure to Hold Blood Pressure Medication per Physician Parameters
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically regarding the administration of metoprolol, a blood pressure medication, outside of physician-ordered parameters. For three residents reviewed, staff administered metoprolol even when blood pressure readings were below the minimum thresholds specified in the orders. For example, one resident with a history of hypertension, cerebral palsy, and epilepsy received metoprolol on three occasions when her systolic or diastolic blood pressure was below the ordered parameters. The medication administration records (MAR) confirmed that the medication was given despite these readings, and the nurse involved acknowledged the error during an interview. Another resident with chronic obstructive pulmonary disease, heart failure, and hypertension was also administered metoprolol on two occasions when her blood pressure was not within the required parameters. The MAR indicated that medication aides documented the administration of the medication despite blood pressure readings below the physician's specified limits. Similarly, a third resident with end-stage heart failure and hypertension received metoprolol on three occasions when his blood pressure was below the ordered parameters, as documented in the MAR and confirmed by staff interviews. Interviews with nursing staff and facility leadership revealed a lack of consistent monitoring and accountability regarding medication administration. Staff members were not always aware of the specific parameters for holding blood pressure medications, and facility leadership acknowledged challenges in reviewing MARs due to staffing constraints. Medication pass audits indicated previous issues with adherence to physician orders, and the facility's policy required orders to be consistent with safe and effective practices, which was not followed in these instances.