Failure to Monitor Blood Pressure Prior to Metoprolol Administration
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was adequately monitored as required by physician orders. Specifically, a resident with a diagnosis of hypertension had a physician order for Metoprolol Tartrate 100 mg twice daily, with instructions to hold the medication if the resident's systolic blood pressure was less than 120. However, review of the resident's Medication Administration Records (MAR) for several months showed that blood pressure readings were not documented prior to the administration of Metoprolol, despite the order's explicit requirement. The MARs indicated that the medication was administered, but there was no evidence that blood pressure was checked at the required times. Interviews with nursing staff confirmed that blood pressure readings should be documented in the MAR before administering medications with such parameters. However, staff acknowledged that the necessary documentation was missing and that the electronic medical record system did not prompt nurses to take and record blood pressure prior to administration due to incomplete order entry. As a result, there was no assurance that the medication was withheld when the resident's systolic blood pressure was below the specified threshold, as required by the physician's order.