Failure to Follow Medication Parameters for Antihypertensive Administration
Penalty
Summary
The facility failed to ensure that physician-ordered parameters for antihypertensive medication administration were followed for a resident with multiple complex medical conditions, including hypertension, respiratory failure, and hypercalcemia. The physician's order specified that Metoprolol should be held if the resident's systolic blood pressure (SBP) was less than 110 or heart rate (HR) was less than 70. Despite these clear parameters, medication administration records showed that Metoprolol was given on multiple occasions when the resident's SBP was below the ordered threshold, with documented readings as low as 80/48. Interviews with several LPNs revealed uncertainty or lack of recall regarding adherence to the medication parameters, and some staff indicated they would have held the medication if aware of low blood pressure or the specific parameters. The DON and prescribing providers confirmed that medications should not be administered outside of ordered parameters and that they were not notified of these occurrences. Facility policy required medications to be administered as prescribed, including adherence to any parameters, but this was not followed in the resident's case.