Failure to Administer Medication as Ordered
Penalty
Summary
A deficiency was identified when a resident with diagnoses including Alzheimer's disease, heart failure, and hypertensive chronic kidney disease did not receive medication as ordered. The resident's care plan required administration of metoprolol tartrate 25 mg twice daily, with instructions to check blood pressure (BP) before administration and to hold the medication if BP was less than 100/50 or heart rate was less than 60. Review of the Medication Administration Records (MAR) for June, July, and August showed that the medication was held on several occasions when the resident's BP and heart rate were within the parameters to administer, or when no vital signs were recorded to justify holding the dose. Specifically, the medication was withheld on multiple dates despite recorded BP and heart rate readings that did not meet the criteria for holding the medication, and in some instances, there was no documentation of vital signs to support the decision to withhold. During an interview, the Director of Nursing was unable to provide further information regarding the rationale for holding the medication when the parameters were not met. This failure to administer medication as ordered constituted a deficiency in following physician orders and the resident's care plan.