Failure to Follow Metoprolol Hold Parameters for Two Residents
Penalty
Summary
The deficiency involves nursing staff administering Metoprolol outside of ordered parameters for two residents, contrary to physician orders. Resident #2, admitted with hypertension and severe cognitive impairment, had a physician order for Metoprolol 25 mg once daily with instructions to hold the medication if the heart rate was less than 60 or if the systolic blood pressure was less than 100 or diastolic blood pressure was less than 60. Review of the December 2025 MAR showed that Metoprolol was administered on multiple dates when the resident’s heart rate was below 60: on 12/13 and 12/14 with a heart rate of 52 by one nurse, on 12/16 with a heart rate of 53 by another nurse, on 12/18 with a heart rate of 55 by a third nurse, and on 12/20 with a heart rate of 59 by the same nurse who administered on 12/16. The Medical Director confirmed there were no negative outcomes but stated he expected staff to follow the ordered parameters. The nurses involved, when interviewed, acknowledged that the medication should have been held and characterized the administrations as oversights. Resident #3, admitted with hypertension and cognitively intact per a quarterly MDS, had a physician order for Metoprolol 50 mg three times daily with instructions to hold the medication if the heart rate was less than 60 or if the systolic blood pressure was less than 100 or diastolic blood pressure was less than 60. Review of the January 2026 MAR showed that Metoprolol was administered on 1/2/26 at the 1:00 PM dose and the 9:00 PM dose when the systolic blood pressure was documented as 97, below the ordered hold parameter. The Medical Director again noted no negative outcomes but expected adherence to the parameters. One of the nurses who administered the medication on that date verified the administration outside the ordered parameter and stated it was an oversight. The DON stated she expected nursing staff to follow physician orders, including parameters for holding blood pressure medications.
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