F0760

E

Failure to Follow Blood Pressure Parameters for Metolazone Administration

Lumberton, North Carolina Survey Completed on 02-19-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in which the facility failed to ensure a resident was free from significant medication errors related to administration of Metolazone, a diuretic prescribed with specific blood pressure hold parameters. The physician’s order dated 9/5/25 directed that Metolazone 5 mg be given orally on Monday, Wednesday, and Friday for edema, with instructions to hold the dose if the systolic blood pressure was less than 110 or the diastolic blood pressure was less than 60. Despite these parameters, review of the Medication Administration Records (MARs) from September 2025 through February 2026 showed that the medication was repeatedly administered when the resident’s blood pressure readings were outside the ordered limits.

The resident involved was admitted with diagnoses including heart failure, hypertension, and kidney disease, and received diuretic medications. MAR review revealed that Metolazone was documented as given on multiple dates over several months when either the systolic blood pressure was below 110 or the diastolic blood pressure was below 60. These administrations occurred on numerous specific dates in September, October, November, and December 2025, as well as January and February 2026, totaling 57 doses given contrary to the ordered hold parameters. Progress notes from 9/10/25 through 2/11/26 contained no documentation of any change in the resident’s condition during this period.

During interviews, the nurse who administered the medication on all of the identified dates acknowledged giving Metolazone despite the blood pressure readings and stated she misunderstood the order, believing the medication should be held only if both systolic and diastolic pressures were below 110/60. The nurse reported she was new and consistently assigned to care for this resident. The resident was observed sitting in a wheelchair, in no distress, and voiced no concerns with care. The Nurse Practitioner confirmed that the order required holding Metolazone if either the systolic was less than 110 or the diastolic was less than 60 and stated she was not aware the medication had been given outside these parameters. The Consultant Pharmacist stated that taking Metolazone when not indicated could cause hypotension and increase fall risk. The Director of Nursing reported she was not aware that Metolazone had continued to be administered outside the ordered parameters and that the resident had no falls and no change in condition.