Failure to Hold Blood Pressure Medication per Physician Parameters
Penalty
Summary
Nursing staff failed to follow physician-ordered parameters for administering a blood pressure medication to a resident with a history of hypertension and episodes of low blood pressure. The physician's order specified that Metoprolol Succinate 25 mg should be held if the resident's systolic blood pressure (SBP) was less than 110 mm/Hg. Despite this, medication administration records showed that the medication was given on multiple occasions when the resident's SBP was below the ordered threshold. Specific instances included administration when SBP readings were 101, 105, 93, 103, 97, and 109 mm/Hg, all of which were below the 110 mm/Hg parameter set by the physician. Interviews with nursing staff revealed a lack of awareness or misunderstanding of the specific hold parameters, with one nurse incorrectly recalling the threshold as 100 mm/Hg and another unable to explain why the medication was administered outside the parameters. The nurse practitioner and Director of Nursing both confirmed that the medication should not have been given when the SBP was below 110 mm/Hg, as per the physician's order. The failure to adhere to the medication hold parameters resulted in the resident receiving unnecessary doses of blood pressure medication.