Failure to Follow Vital Sign Parameters Before Administering Antihypertensive Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a nurse was competent in medication administration according to physician orders and facility policy. The facility’s Medication Administration policy, revised 9/10/25, required that when medications had vital sign parameters, vital signs must be taken prior to preparing the medication. Resident #21, admitted with interstitial lung disease and heart failure, had a physician’s order for Metoprolol Succinate ER 12.5 mg by mouth in the morning for hypertension, with instructions to hold the dose for systolic blood pressure (SBP) less than 100 or heart rate less than 50. On 3/30/26 at 9:35 AM, LPN #2 administered the resident’s medications, including Metoprolol, and only checked the resident’s blood pressure after the medication was given, contrary to the order and policy requiring vital signs beforehand. The CNO confirmed that the nurse should have checked the resident’s vital signs before administering the medication. Review of LPN #2’s oral medication administration competency form showed she had completed training, including the requirement that vital sign parameters be taken per facility practice before pouring medication, yet this was not followed in practice. This failure was identified for 1 of 5 nurses observed during medication administration and was determined to have the potential to affect all residents in the facility and increase the risk of harm to residents.
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