Failure to Administer Medication According to Physician Orders
Penalty
Summary
A deficiency was identified when a resident with hypertension did not receive medication administration in accordance with physician orders. The resident was prescribed metoprolol tartrate with specific instructions to hold the medication if the systolic blood pressure was 110 mmHg or less, or if the heart rate was below 60 beats per minute. On several occasions, documentation showed that the resident's systolic blood pressure was below the specified threshold, yet the medication was not held as ordered. Additionally, there were instances where there was no documented evidence that the resident's blood pressure or heart rate was obtained prior to administering the medication. The clinical record review and staff interviews confirmed these lapses in following physician orders. The Director of Nursing acknowledged that the medication was not held as required and that vital signs were not always obtained before administration. These findings were based on a review of the resident's Medication Administration Record and clinical documentation over a three-month period.