Failure to Document and Follow Hold Parameters for Medication Administration
Penalty
Summary
Staff failed to obtain and document a resident's vital signs prior to administering metoprolol, a medication with physician-ordered hold parameters. The resident had multiple diagnoses, including chronic obstructive pulmonary disease, type 2 diabetes mellitus with diabetic polyneuropathy and hypoglycemia, hypertension, cognitive communication deficit, edema, and bradycardia. Physician orders required that metoprolol be held if the heart rate was less than 55 or systolic blood pressure was less than 110, and that blood pressure and heart rate readings be obtained twice daily for seven days. The Medication Administration Record (MAR) showed that vital signs were documented as ordered from 4/18/25 through 4/26/25, but metoprolol was administered on several occasions when the heart rate was below the ordered threshold. After 4/26/25, the MAR did not include documentation of heart rate or blood pressure readings to verify the safety of administering metoprolol, except for one instance on 5/3/25. Despite the lack of required documentation, the medication continued to be administered. Interviews with staff confirmed that vital signs should have been obtained and recorded prior to administering medications with hold parameters, and that there was no verification of vital signs before administration as required by physician orders and facility policy.