Failure to Follow Physician-Ordered Parameters for Antihypertensive Medication
Penalty
Summary
The facility failed to ensure that physician-ordered parameters for antihypertensive medication administration were followed, resulting in the administration of unnecessary medications to a resident. The resident had multiple diagnoses, including atrial fibrillation, heart failure, malnutrition, COPD, diabetes, osteoarthritis, esophageal cancer, and atherosclerotic heart disease. The physician's order for Metoprolol Succinate ER specified that the medication should be held if the systolic blood pressure (SBP) was less than 100, diastolic blood pressure (DBP) was less than 60, or heart rate (HR) was less than 60. Despite these parameters, medication administration records showed that the resident received Metoprolol on multiple occasions when their blood pressure readings were below the specified thresholds. Interviews with staff revealed a lack of awareness and adherence to the ordered parameters. One LPN admitted to administering the medication even when the resident's blood pressure was outside the prescribed limits, stating they did not realize the error at the time. The Director of Nursing confirmed that all medications should be administered or held according to written parameters. This failure to follow physician orders led to the administration of unnecessary antihypertensive medication to the resident.