Failure to Administer Ordered Antihypertensive Medication Due to Missed Transcription
Penalty
Summary
A deficiency occurred when a male resident with a history of acute on chronic diastolic heart failure, type 2 diabetes mellitus, hyperlipidemia, hypertension, and atrial fibrillation did not receive his prescribed Metoprolol succinate extended-release 50 mg tablet once daily for hypertension for a period of 11 days. The resident's medication regimen was changed by a nurse practitioner, discontinuing Metoprolol tartrate and initiating Metoprolol succinate per the resident's VA doctor's recommendation. However, the new order for Metoprolol succinate was not entered into the facility's medication administration system, resulting in the resident not receiving the medication as ordered from 09/14/2024 to 09/24/2024. During this period, the resident continued to receive other medications for heart failure and hypertension, including Entresto, Lasix, and Spironolactone. Blood pressure readings taken during the missed medication period showed values that were generally stable, though some readings were low. The resident was aware of the missed doses but reported no changes in his condition and did not experience any adverse effects during the 11 days without Metoprolol succinate. Interviews with nursing staff and the DON revealed uncertainty about who was responsible for updating the new medication order in the system. The nurse practitioner who made the order was no longer employed at the facility, and it was unclear whether the order was communicated and transcribed according to facility procedures. The failure to update and transcribe the new medication order led to the resident missing the prescribed medication for hypertension for 11 days.