Failure to Ensure Drug Regimen Free from Unnecessary Medications
Penalty
Summary
A resident with a history of atrial fibrillation and hypotension was admitted to the facility and prescribed Metoprolol Tartrate, with specific parameters to hold the medication if the systolic blood pressure was less than 100. Upon admission, the resident's blood pressure readings were consistently low, with the highest being 78/48. Despite these low readings, the medication was administered on multiple occasions, as documented in the Medication Administration Record (MAR). The original physician's order included parameters to hold Metoprolol for low systolic blood pressure, but after a revision to the administration times by a registered nurse, these parameters were no longer visible in the order. Staff interviews confirmed that the medication was given even when the resident's blood pressure was below the specified threshold, and staff were unaware that the parameters had been removed from the order. This resulted in the resident receiving unnecessary medication contrary to the original physician's instructions.