Failure to Assess Blood Pressure Parameters Before Administering Antihypertensive Medication
Penalty
Summary
A deficiency was identified when a resident with diagnoses including dementia, hypertension, type 2 diabetes, and chronic kidney disease was administered Metoprolol without proper assessment of physician-ordered parameters. The physician's order specified that the medication should be held if the resident's systolic blood pressure was less than 110 or pulse was less than 60. However, review of the electronic medication administration record (eMAR) showed that the resident received Metoprolol multiple times without blood pressure monitoring prior to administration. On one occasion, the resident's blood pressure was documented as 97/61, which was below the ordered threshold, yet the medication was still administered. The Director of Nursing confirmed that blood pressure readings were not consistently documented before medication administration, as required by both physician orders and facility policy. The facility's policy mandates that vital signs be obtained and recorded as necessary prior to medication administration, but this was not followed in the resident's case.