Inaccurate Documentation of Blood Pressure Medication Administration
Penalty
Summary
The facility failed to maintain a complete and accurate medication administration record for a resident with a diagnosis of high blood pressure. Physician orders specified that Metoprolol Succinate 25 mg should be held if the resident's systolic blood pressure (SBP) was less than 110 mm/Hg. However, review of the medication administration records for April and May 2025 showed that the medication was documented as given on several occasions when the recorded SBP was below the specified threshold. Specifically, on three separate dates, the medication was signed off as administered despite SBP readings of 105/60 mm/Hg, 105/58 mm/Hg, and 108/64 mm/Hg, all of which were below the hold parameter. Interviews with the involved nursing staff and medication aide revealed that these were documentation errors. Staff admitted to inaccurately recording that the medication was given when it should have been documented as held, or to recording the wrong blood pressure value. The nurse practitioner and Director of Nursing both stated that they expect accurate documentation of medication administration, as this information is relied upon for clinical decision-making and ongoing care.