Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
Staff failed to follow physician orders during medication administration for a resident with a history of hypertension, superficial frostbite, tissue necrosis, homelessness, and cerebral vascular accident. The resident's care plan required evaluation of blood pressure and heart rate, and a physician's order specified that Metoprolol Tartrate should be held if the systolic blood pressure was under 110 or the heart rate was below 60. Despite these instructions, the medication was administered multiple times when the resident's systolic blood pressure was below the specified threshold. Review of the Medication Administration Record showed that on several occasions, the resident received Metoprolol Tartrate even though their systolic blood pressure readings were below 110, contrary to the physician's order. The Director of Nursing and Assistant Director of Nursing confirmed that the medication was given outside the prescribed parameters. Facility policy required medications to be administered according to orders, including any specified time frames. No negative effects were documented as a result of the medication administration.