Failure to Follow Blood Pressure Parameters for Antihypertensive Medication Administration
Penalty
Summary
Nursing staff failed to follow physician-ordered blood pressure (BP) parameters for the administration of metoprolol succinate ER in one resident with a history of hypertension, heart failure, cardiomyopathy, and atrial fibrillation. The resident's care plan specifically indicated the need to hold the antihypertensive medication if the systolic BP (SBP) was below 110 mmHg. Despite this, the medication was administered on four separate occasions in April 2025 when the resident's SBP was below the prescribed threshold, as documented in the Medication Administration Record (MAR). The Director of Nursing (DON) confirmed during interviews and record reviews that the medication should not have been given under these circumstances and acknowledged that staff did not adhere to the hold parameters. Facility policy also required nurses to follow precautionary instructions on prescription labels, including parameters. Manufacturer's prescribing information for metoprolol succinate ER lists hypotension as a common adverse reaction, further underscoring the importance of following such parameters.