Failure to Follow Physician's Orders for Blood Pressure Medication Administration
Penalty
Summary
Facility staff failed to follow physician's orders and professional standards of quality when administering blood pressure medication to Resident #9. The physician's order required Metoprolol 25 mg to be given twice daily with instructions to hold the medication if the systolic blood pressure was less than 100 mmHg. Despite this, the medication was administered twice daily throughout July 2025, while blood pressure readings were only documented on four occasions during the month. Interviews with an LPN revealed that blood pressure should be checked prior to administration when parameters are ordered, and the DON confirmed that undocumented readings were likely not performed. This indicates that the required blood pressure monitoring prior to medication administration was not consistently completed or documented as ordered.