Failure to Hold Antihypertensive Medication per Physician Order
Penalty
Summary
The facility failed to ensure that pharmaceutical services met the needs of a resident by not holding a prescribed antihypertensive medication, Metoprolol, as ordered by the physician. The physician's order specified that the medication should be held if the resident's systolic blood pressure (SBP) was less than 120. Despite this, the medication was administered on two occasions when the resident's SBP was 118/62 and 110/64, respectively. There was no documentation in the medication administration records (MARs) or nurses' notes indicating that the medication was held or providing a reason for not holding it, as required by the physician's order and facility policy. The resident involved was an older adult with a diagnosis of hypertension and demonstrated intact cognitive skills, as indicated by a BIMS score of 15. Interviews with staff revealed that the medication should have been held according to the parameters, and the lack of documentation made it unclear whether the medication was administered or appropriately withheld. Staff acknowledged the error in documentation and the need to accurately record when medications are held or given, especially when specific parameters are outlined in the physician's orders.