Failure to Follow Medication Hold Parameters and Notify Provider for Low Heart Rate
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received treatment and care in accordance with professional standards of practice related to administration of blood pressure and antiarrhythmic medications with ordered parameters. The resident was admitted with diagnoses including hypertension and atrial fibrillation and had a care plan addressing hypertension, with interventions to administer antihypertensive medications as ordered and obtain vital signs as ordered. Physician orders dated 12/7/2025 directed that metoprolol 100 mg twice daily be held for systolic blood pressure less than 110 or heart rate (HR) less than 60, and that amiodarone 200 mg once daily be held for HR less than 60. Review of the December 2025 and January 2026 MARs showed multiple instances where metoprolol and amiodarone were documented as administered despite HRs below the ordered parameters. Specifically, metoprolol was documented as given on several dates when the resident’s HR ranged from 48 to 58, all below the hold parameter of HR less than 60. Amiodarone was also documented as administered on one date when the HR was 58, below the ordered parameter. At the same time, the MAR showed that metoprolol was held on numerous occasions in both December and January due to low HR, indicating repeated occurrences where the resident’s HR was below the ordered threshold. Staff interviews confirmed that CMTs were expected to obtain vital signs prior to administering metoprolol or amiodarone and to hold the medications and notify the nurse if vital signs were outside the ordered parameters. The CMT and RN acknowledged that, based on the documented HRs, the medications should not have been administered on the identified dates. The DON and Infection Preventionist also acknowledged that the medications were documented as administered when the HR was below the parameters. Record review did not show evidence that the provider was notified of the multiple held doses of metoprolol due to low HR, and the provider stated she was unaware that the medication was being held often and would have expected notification when the medications were held, as well as adherence to the ordered parameters.
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