Failure to Hold Metoprolol per Physician Parameters Resulting in Hypotension
Penalty
Summary
The facility failed to ensure that medications with physician-ordered parameters were safely administered for a resident prescribed metoprolol for hypertension. The physician's order specified that metoprolol should be held if the resident's systolic blood pressure (SBP) was less than 100 or heart rate (HR) was less than 60. On multiple occasions, including specific dates, the medication was administered despite the resident's vital signs being outside of these parameters or not documented at all. For example, on one date, the resident's blood pressure was recorded as 90/66 and 89/65, both below the hold threshold, yet the medication was still given. Additionally, there were instances where vital signs were not recorded on the medication administration record (MAR) prior to administration. Interviews with licensed nurses confirmed that they were aware of the hold parameters and acknowledged that the medication should not have been administered when the resident's vital signs were outside the prescribed limits. The failure to adhere to these parameters resulted in the resident experiencing hypotension, requiring emergency evaluation and observation. Facility policy required medications to be administered as prescribed and in accordance with physician orders, which was not followed in this case.