Failure to Monitor Blood Pressure Before Administering Antihypertensive Medications
Penalty
Summary
Staff failed to monitor a resident’s blood pressure prior to administering antihypertensive medications. On 02/25/26 between 8:55 A.M. and 9:05 A.M., an RN administered lisinopril 20 mg and metoprolol succinate 50 mg to Resident #18 and obtained the resident’s blood pressure only after giving the medications. In a subsequent interview, the RN confirmed that the resident’s blood pressure should have been taken before administering these medications. Review of the February 2026 MAR for this resident showed no specific parameters for holding lisinopril or metoprolol tartrate, although there was a designated area to document blood pressure and pulse with metoprolol tartrate administration. The MAR indicated five instances when metoprolol tartrate was not administered due to low blood pressure readings, including 90/67, 93/51, 95/61, and 105/90 on various mornings, and additional readings of 99/63 and 98/52 on other dates. In an interview, the DON stated that blood pressures should ideally be monitored prior to giving medications that could affect blood pressure, especially for residents with a history of low readings. This deficiency was investigated under Complaint Number 2706361.
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