Failure to Follow Physician's Orders for Medication Administration
Penalty
Summary
Staff failed to administer medications according to physician's orders for one resident. The physician's orders specified that Metoprolol Succinate ER 50 mg should be given once daily for hypertension, but held if the systolic blood pressure (SBP) was less than 120, diastolic blood pressure (DBP) was less than 80, or heart rate (HR) was less than 60. Losartan Potassium 100 mg was also ordered once daily for hypertension, to be held if SBP was less than 120. Despite these parameters, the Medication Administration Record (MAR) showed that both medications were administered on multiple occasions when the resident's SBP was less than 120 or DBP was less than 80, contrary to the physician's instructions. The Director of Nursing (DON) confirmed during an interview that the resident received Metoprolol Succinate and Losartan Potassium outside the prescribed parameters, constituting a significant medication error. The DON stated that the expectation is for nurses to follow the orders as written, hold the medication when indicated, and call the physician to verify instructions. The documentation and interview confirm that the medications were not administered in accordance with the physician's orders, resulting in a deficiency.