Failure to Notify Physician of Held Blood Pressure Medication
Penalty
Summary
The facility failed to ensure that a physician was consulted regarding the need to alter treatment for a resident with a history of hypertension and coronary artery disease. The resident, who had moderately impaired cognition, was prescribed metoprolol tartrate 100 mg twice daily with specific parameters to hold the medication if systolic blood pressure (SBP) was less than 110, diastolic blood pressure (DBP) less than 50, or heart rate less than 50. Over the course of August 2025, the medication was held on five occasions due to blood pressure readings outside the prescribed parameters. However, there was no documentation or indication that the physician was notified about the medication being held on these occasions. Interviews with facility staff revealed that the expectation was for the physician to be notified each time a medication with parameters was held, and that such notifications should be documented in the resident's electronic record. The Director of Nursing and the Registered Dietitian Consultant both acknowledged that physician notification was overlooked in this case. The facility's policy required nursing staff to observe changes, make assessments, and notify the physician as indicated, but this process was not followed for the resident in question.