Failure to Monitor Blood Pressure Prior to Beta-Blocker Administration Resulting in Significant Medication Error
Penalty
Summary
A significant medication error occurred when a resident with multiple complex medical conditions, including encephalopathy, seizure disorder, COPD, respiratory failure, diabetes, and kidney failure, was administered Metoprolol, a beta-blocker, without prior blood pressure monitoring. The resident was admitted for respite care and was dependent on staff for most activities of daily living. On the morning of the incident, the resident was observed to be lethargic, with low blood pressure and oxygen saturation, yet the nurse proceeded to administer several medications, including Metoprolol and Oxycodone, without verifying the resident's blood pressure at the time of administration. The nurse later acknowledged that the resident's systolic blood pressure had been reported as under 90 earlier in the shift and admitted to not checking the blood pressure before giving the medication, despite knowing that Metoprolol should be held if the systolic blood pressure is less than 100. The nurse also did not notify the physician of the resident's condition or the administration of the medication under these circumstances. Other staff members reported that the resident was non-responsive, required sternal rubs to be awakened, and had poor oxygenation and color, yet these changes in condition were not communicated to the physician or the care management organization as required. The resident subsequently became unresponsive, with a heart rate of 30, respirations of 6, and oxygen saturation of 57%. Emergency services were called, and the resident was transferred to the hospital after receiving Narcan, which temporarily improved responsiveness. Interviews with staff and review of records confirmed that blood pressure monitoring protocols were not followed, abnormal vital signs were not documented or reported appropriately, and there was a lack of communication regarding changes in the resident's condition and medication administration.