Failure to Follow Physician-Ordered Parameters for Blood Pressure Medication Administration
Penalty
Summary
A deficiency occurred when a resident with multiple cardiac and vascular diagnoses, including non-rheumatic aortic stenosis, hypertension, atrial fibrillation, and heart disease, received Metoprolol Tartrate despite physician orders specifying parameters for administration. The physician's order directed staff to hold the medication if the resident's blood pressure was less than 110/65 or if the heart rate was less than 65. However, medical record review revealed multiple instances over several months where the medication was administered even when the resident's blood pressure or heart rate was below the specified thresholds. Staff interviews confirmed a misunderstanding of the physician's order, with staff indicating they would only hold the medication if both blood pressure and heart rate were below parameters, rather than either one. The physician clarified during the survey that the medication should have been held if either parameter was below the threshold. The facility's failure to follow the physician's order resulted in the resident receiving unnecessary medication doses outside of the prescribed parameters.