Failure to Follow Physician Orders for Antihypertensive Medication Parameters
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s orders for administration of an antihypertensive medication for one resident. Record review showed that a cognitively intact resident with diagnoses including congestive heart failure, chronic kidney disease stage 3, type 2 diabetes mellitus, and acute metabolic acidosis had a physician’s order for metoprolol 25 mg twice daily for hypertension, with instructions to hold the medication if systolic blood pressure was less than 110 mm/Hg or pulse was less than 60 beats per minute. The Medication Administration Records for November and December 2025 documented that nursing staff administered metoprolol on multiple occasions when the resident’s systolic blood pressure was below the ordered hold parameter, including readings of 102/42 mm/Hg, 102/80 mm/Hg, and 104/73 mm/Hg. During interview, the Assistant Director of Nursing acknowledged that nursing staff should have followed the physician’s orders, and the facility’s policy on Provisions of Physician Ordered Services stated that physician-ordered services are to be provided according to professional standards of quality. This citation relates to Intake 27044933,1-37.
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