F0760

E

Failure to Follow BP Parameters for Antihypertensive Medications

North Huntingdon, Pennsylvania Survey Completed on 01-15-2026

Penalty

No penalty information released

Summary

The facility failed to ensure residents were free from significant medication errors by not following physician orders and facility policy for safe medication administration and required monitoring. Facility policy dated 04/01/25 required that medications be administered in a safe and effective manner and that vital signs or other monitoring parameters ordered or deemed necessary be obtained and recorded prior to administration. For one resident with COPD and high blood pressure, a physician order dated 3/20/25 directed that 12.5 mg of metoprolol be given once daily and held if the systolic blood pressure was less than 100 mm Hg. Review of the January 2026 MAR showed that this medication was administered on multiple dates when the documented systolic blood pressures were below 100 mm Hg, including readings of 98/61, 98/61, 98/63, 87/56, and 97/54.

For another resident with diabetes and high blood pressure, a physician order dated 12/27/25 directed that 5 mg of lisinopril be given once daily and held if the systolic blood pressure was less than 120 mm Hg. Review of this resident’s record failed to show any documentation of a blood pressure measurement after 12/29/25, despite the order requiring blood pressure monitoring to determine whether the medication should be administered or held. During an interview, the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to ensure that residents were free of significant medication errors for two of five residents reviewed.