Failure to Notify Physician of Resident's Low Blood Pressure While on Metoprolol
Penalty
Summary
The facility failed to promptly notify and consult with a physician when a resident experienced consistently low blood pressure while taking Metoprolol, a medication known to lower blood pressure. Despite the resident's history of hypertension, COPD requiring continuous oxygen, and a recent hospital discharge for transient hypotension and C. diff infection, the facility continued to administer Metoprolol without informing the physician of multiple low blood pressure readings. The resident's blood pressure readings were frequently below the facility's EHR low parameter of 90/60 mm Hg, with several instances of systolic blood pressure below 90, which should have triggered clinician notification according to INTERACT guidelines and the facility's own policy. The EHR system flagged these readings as low, but no notification was made to the physician. The Director of Nursing stated that there were no specific blood pressure parameters for the resident and expected nurses to use their judgment, but was unaware of the EHR's set parameters. The physician confirmed that she had not been notified of the low blood pressures and would have expected to be informed if the systolic blood pressure dropped below 100. The facility was aware of the resident's low blood pressure readings, continued to administer Metoprolol, and did not communicate these findings to the physician, resulting in a failure to follow the facility's policy for notification of changes in a resident's condition.