Failure to Document Required Vital Signs Before Administering Antihypertensive Medication
Penalty
Summary
Staff failed to follow physician's orders for two residents who had diagnoses of hypertension and were prescribed Metoprolol. For both residents, the orders specified that staff were to administer 25 mg of Metoprolol twice daily, but only if the systolic blood pressure was at least 90 mmHg and the heart rate was at least 60 beats per minute. The orders also required staff to hold the medication if these parameters were not met. Review of the Medication Administration Records for both residents showed that Metoprolol was administered twice daily over an 11-day period without documented evidence that blood pressure and heart rate were checked prior to administration. This lack of documentation was confirmed by the Director of Nursing, who acknowledged that there was no evidence staff obtained the required vital signs before giving the medication as ordered.