Failure to Follow Hold Parameters for Cardiac Medication
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order with specific vital sign parameters for a resident’s cardiac medication. The resident had diagnoses including atrial fibrillation, hypertension, and hypotension. A physician order dated 3/14/26 directed that metoprolol succinate ER 25 mg be given once daily by mouth, with instructions to hold the medication if the resident’s blood pressure was less than 100/50 mm/Hg and/or pulse was less than 60 beats per minute. Review of the March 2026 Medication Administration Record showed that on 3/17/26 the resident’s blood pressure was documented as 96/48 mm/Hg and pulse as 54 beats per minute, yet the metoprolol succinate ER was administered. Further review of the Medication Administration Record indicated that on 3/19/26 the resident’s pulse was documented as 56 beats per minute, and the metoprolol succinate ER was again administered despite the physician’s hold parameters. During an interview, the DON confirmed that the metoprolol succinate ER 25 mg should not have been given on those dates due to the low pulse rate and/or low blood pressure, as specified in the physician’s order. The facility’s current policy titled “Following Physician orders/Parameters,” dated April 2024, states that its purpose is to administer resident care in a safe and effective manner and to follow physician orders and ordered parameters, which was not done in this case.
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