Failure to Follow Physician Orders for Blood Pressure Medication Administration
Penalty
Summary
Staff failed to follow physician orders regarding the administration of blood pressure medication for two residents. For one resident with hypertension, a physician ordered that metoprolol succinate be administered twice daily, but not if the resident's heart rate was below 60 beats per minute (BPM). Review of the Medication Administration Records (MARs) showed that the medication was administered multiple times in April and May without any documentation that the resident's heart rate was checked prior to administration, as required by the order. The Assistant Director of Nursing confirmed that there was no evidence of heart rate assessment before giving the medication. For another resident with hypertension and diabetes, a similar physician order was in place for metoprolol tartrate, specifying to withhold the medication if the heart rate was less than 60 BPM. The MARs indicated that the medication was administered on four occasions in April and May when the resident's heart rate was actually below 60 BPM. The Director of Nursing confirmed that the medication was given outside of the prescribed parameters. These findings were based on policy review, clinical record review, and staff interviews.