F0684

D

Incorrect Metoprolol Dosage Administered Contrary to Physician Order

Chicago, Illinois Survey Completed on 01-22-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to administer a prescribed medication at the correct dosage in accordance with the physician’s order, resident’s needs, and facility policy. During a medication pass observation, an LPN (V11) dispensed and administered one whole 25 mg tablet of Metoprolol Tartrate to a resident (R6), despite the medication container label directing that 0.75 of a 25 mg tablet (18.75 mg) be given every 12 hours. Shortly after administration, V11 confirmed she had given a full 25 mg tablet and acknowledged that the resident was supposed to receive 18.75 mg and that she did not follow the doctor’s order. The resident’s active order and MAR both documented Metoprolol Tartrate 25 mg tablets to be given as an 18.75 mg dose twice daily for hypertension.

A second LPN (V12) reported that she regularly worked on the unit where the resident resided and, when assigned to this resident, she dispensed the medication from the same container and consistently administered one whole tablet, believing that the whole tablet was 18.75 mg. Upon re-checking the container, V12 recognized that she had been administering 25 mg instead of the ordered 18.75 mg and stated she had not followed the order. The DON (V2) clarified that the order required giving a half tablet plus a quarter tablet of the 25 mg Metoprolol to equal 18.75 mg, and that giving a whole 25 mg tablet did not follow the physician’s order. The resident’s records showed diagnoses including hypertension, tachycardia, oxygen dependence, and a severely impaired cognitive status (BIMS score of 5). Facility job descriptions for RNs and LPNs, as well as the medication administration policy, required medications to be prepared and administered as ordered by the physician, including the right dose, which was not done in this case.