F0757

D

Failure to Implement and Follow Metoprolol Orders and Hold Parameters

Milwaukee, Wisconsin Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident’s drug regimen was administered and monitored according to physician-ordered parameters and that new cardiac medication orders were timely implemented. The resident, who had diagnoses including CHF, hemiplegia/hemiparesis after stroke, hypertension, and atrial fibrillation, was sent to the ED after a fall and was found to be in A Fib with RVR, likely due to fluid overload. In the ED, oral metoprolol was used for rate control, and upon return to the facility, a verbal physician order dated 11/27/25 directed Metoprolol Tartrate 25 mg once daily for heart failure and A Fib. However, this order was not implemented until 12/1/25, and the November MAR contained no entry for metoprolol.

When Metoprolol Tartrate 25 mg was finally entered on the December MAR, it included parameters to hold the medication for HR < 60 or systolic BP < 100. Despite these parameters, the resident received metoprolol on multiple occasions when it should have been held: on 12/2/25 when the pulse was documented as 60, on the morning of 12/9/25 when the pulse was 49, on the morning of 12/14/25 when the systolic BP was 98 and pulse 50, and on the morning of 12/19/25 when the systolic BP was 79. The December MAR showed metoprolol 25 mg once daily starting 12/2/25 and discontinued 12/8/25, then increased to 25 mg twice daily starting 12/9/25, with the same hold parameters, yet the parameters were not followed on the dates noted.

Hospice documentation showed that on 11/28/25 a hospice RN faxed a new order for metoprolol 25 mg once daily to control A Fib after the ED visit, and on 12/1/25 the same hospice RN documented that the metoprolol order from the prior week was not in the electronic system and refaxed it, instructing facility staff that the resident needed a dose that day due to ongoing A Fib with HR in the 115–130s. Interviews with the DON and an RN revealed that floor nurses are responsible for reviewing hospital return paperwork and implementing hospice faxed orders, and that hospice is expected to communicate new orders directly to the nurse. The RN stated she does not review hospice notes, and both the RN and DON acknowledged that medication hold parameters ordered by the physician should be followed. The surveyor determined that the metoprolol order was not implemented as ordered and that the medication was administered on several dates despite vital signs being outside the ordered parameters.