Failure to Notify Physician After Holding Antihypertensive Medication
Penalty
Summary
The facility failed to notify the physician after holding blood pressure medication for a resident with a history of stroke and hypertension. Physician orders specified that Metoprolol Tartrate should be held if the resident's blood pressure was less than 100/55, and the physician should be notified for further instructions. Medication administration records showed multiple instances where Metoprolol was held due to low blood pressure readings, but there was no documentation that the physician was notified as required. Interviews with staff revealed that the expected process was to inform the charge nurse and document the event in the provider's communication book. However, review of the communication book showed no entries regarding the held medication for this resident. The interim DNS and the physician assistant both confirmed there was no evidence of provider notification, and the physician assistant stated he would have adjusted the medication dosage if he had been informed of the low blood pressures.