Significant Medication Error: Blood Pressure Medication Administered Outside Physician Parameters
Penalty
Summary
A deficiency occurred when a male resident with a history of atrial fibrillation, hypertension, and a cardiac pacemaker did not receive his blood pressure medication, Metoprolol, as ordered by the physician. The physician's order specified that Metoprolol 12.5 mg should be administered twice daily by mouth, but to hold the medication if the resident's systolic blood pressure (SBP) was less than 100. Despite this, the medication was administered on six occasions in March when the resident's SBP was below the ordered threshold, with documented readings as low as 88/61. Medication administration records (MAR) and staff interviews confirmed that the medication was given outside of the prescribed parameters. Medication aides involved acknowledged that the medication should not have been administered when the SBP was below 100, and one aide stated it may have been a documentation error. The facility's policy required medications to be administered as prescribed, including adherence to any hold parameters, but this was not followed in these instances. Interviews with the facility's pharmacist, nurse practitioner, and nursing leadership confirmed that the physician's hold order was intended to prevent the resident's blood pressure from dropping too low. The staff involved were aware of the order and the associated risks, and the facility had processes in place for medication administration and monitoring, but these were not effectively implemented, resulting in the resident receiving medication outside of the physician's parameters.