Failure to Follow Physician-Ordered Medication Parameters
Penalty
Summary
Facility staff failed to follow physician-ordered medication parameters for a resident diagnosed with atrial fibrillation and essential hypertension. The resident had a physician order for Metoprolol Succinate ER, with instructions to hold the medication if the systolic blood pressure was less than 100 or the pulse was less than 60. Despite these parameters, the medication was administered on multiple occasions when the resident's pulse was documented below 60, specifically on June 1, 2, 9, 10, and 11, with pulse readings as low as 51. There was no documentation explaining why the medication was given outside of the specified parameters. Additionally, on June 12, the medication was administered when the resident's blood pressure was recorded as 90/54, which was below the physician-ordered threshold. These incidents were confirmed through clinical record review and staff interviews, and the lack of adherence to the medication parameters was discussed with facility leadership. The report does not mention any documentation or justification for administering the medication outside the prescribed limits.