Failure to Hold and Document Blood Pressure Medication per Physician Order
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of hypertension received Metoprolol, a blood pressure medication, despite physician orders to hold the medication if the systolic blood pressure (SBP) was less than 120. On two occasions, the medication was administered when the resident's SBP was 118/62 and 110/64, respectively. There was no documentation indicating that the medication was held as ordered, nor was there any explanation in the nursing notes for not holding the medication. The medication administration record (MAR) did not reflect that the medication was withheld, and the nurse responsible later stated that she documented in error and could not confirm whether the medication was actually held or given. Interviews with staff confirmed that the medication should have been held according to the physician's parameters and that proper documentation was required when medications were not administered. The resident was alert, oriented, and able to communicate her needs at the time of observation. Facility policy required that medications be administered only as ordered by a physician, including adherence to parameters for holding medications. The failure to follow these orders and document actions appropriately constituted a medication error for this resident.