F0760

D

Failure to Follow Metoprolol Hold Parameters Resulting in Medication Errors

Bridgman, Michigan Survey Completed on 01-16-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors related to administration of metoprolol succinate ER. The resident, a female with bipolar disorder, dementia, and delusional disorder, had a physician’s order for metoprolol succinate ER 25 mg by mouth once daily for hypertension, with instructions to hold the medication if the systolic blood pressure was less than 110 or the pulse was less than 60, and to notify the physician. Review of the Medication Administration Records (MARs) for October, November, and December 2025 showed multiple instances where the resident’s systolic blood pressure was documented below 110, yet the metoprolol was still administered on those dates.

Specific blood pressure readings below the ordered parameter included systolic values of 107, 102, 106, 107, 94, and 107 in October; 103, 106, 100, 100, 108, 105, and 109 in November; and 103, 104, 104, 106, 109, and 104 in December, all with documentation that the medication was given. The resident’s medical record contained no documentation that any provider was notified when blood pressure readings were outside the ordered parameters. In interviews, an LPN stated that medications with hold parameters should not be given if vital signs are outside those parameters. The physician assistant and nurse practitioner both reported that, based on the written order, the metoprolol should have been held whenever the systolic blood pressure was below 110, and the nurse practitioner did not recall being notified of any holds. The DON stated her expectation that medications be given per physician orders and acknowledged that if the provider was not contacted and the medication was given when blood pressure was outside parameters, it constituted a medication error.