Failure to Hold Blood Pressure Medication per Physician Order
Penalty
Summary
A facility failed to administer blood pressure medication according to a physician's order for one resident following their re-admission after a hospital stay. The resident had multiple diagnoses, including chronic obstructive pulmonary disease, hypertensive heart disease with heart failure, chronic kidney disease, diabetes, and anxiety disorder. The physician's order for metoprolol specified that the medication should be held if the resident's systolic blood pressure (SBP) was less than 110 or heart rate (HR) was less than 60. Despite this, the medication was administered on two occasions when the resident's SBP was documented as 101/56 and 101/59, both below the specified threshold. A progress note indicated that after one of these administrations, the resident's blood pressure remained low, with a last reading of 85/57, prompting notification of the nurse practitioner and a new order for a one-time dose of Midodrine to address the low blood pressure. The facility's Director of Nursing confirmed in an interview that the metoprolol should have been held per the instructions. The facility's policy on medication administration requires medications to be given in accordance with prescriber orders, which was not followed in this instance.
Plan Of Correction
F684 SS=D Quality of Care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Element 1 Resident #901 no longer remains within the facility. Nurse "A" that completed medication errors received 1:1 education on following parameters noted within blood pressure medication orders. Element 2 All current residents receiving blood pressure medications that have parameters have the potential to be affected by this citation. These residents have had a medication administration record reviewed for the last 7 days to ensure blood pressure medications were administered appropriately. Element 3 Actively scheduled floor nurses have been educated on medication administration policy and specifically following parameters noted within blood pressure medication order. Actively scheduled floor nurses that have not completed this education by the date of compliance will be in-serviced prior to their next shift. Element 4 DHS/Designee will audit 5 residents' administration records that have blood pressure medications with parameters to ensure the assigned nurse followed the parameters listed within the medication order x4 weeks. Findings/trends will be submitted to the QAPI committee for review and recommendation on continued audits. Executive Director is responsible for obtaining compliance. Element 5 July 3rd, 2025