Failure to Follow Physician-Ordered Medication Parameters and Inaccurate Documentation
Penalty
Summary
The facility failed to provide care in accordance with physician-ordered medication parameters for a resident diagnosed with hypertension. The resident had a physician order for Metoprolol Tartrate 25 mg to be administered every eight hours via gastrostomy tube, with specific instructions to hold the medication if the pulse was less than 60 or if the systolic blood pressure (SBP) was less than 100. Clinical record review revealed that the medication was administered on multiple occasions when the resident's SBP was below the ordered threshold, specifically on several dates in May, June, and July 2025. There was no documentation providing a rationale for administering the medication outside of the specified parameters. Additionally, while the facility provided nursing shift report sheets indicating that the medication doses were held on the dates in question, the resident's Medication Administration Record (MAR) did not reflect that the doses were actually held. This discrepancy between the shift report sheets and the MAR documentation was confirmed during a meeting with the Nursing Home Administrator and Director of Nursing. The lack of accurate documentation and adherence to physician orders constituted a failure to provide the highest practicable care as required.