Failure to Follow Hold Parameters for Antihypertensive Medication
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order to hold a blood pressure medication when the resident’s systolic blood pressure (SBP) was below a specified parameter. A resident admitted with hypertension and heart failure had a physician’s order for Metoprolol Tartrate 25 mg, to administer 12.5 mg by mouth every 12 hours, with instructions to hold the dose if SBP was less than 110. Review of the January 2026 MAR showed that the resident received Metoprolol Tartrate for multiple 9:00 PM doses when the SBP was documented below 110, including SBP readings of 109, 109, 99, and 106. The resident’s quarterly MDS indicated the resident was cognitively intact. During an interview, the medication aide who administered several of the doses confirmed that Metoprolol Tartrate was given despite SBP readings below the ordered parameter and stated this was an oversight. Attempts to contact the nurse who administered one of the doses were unsuccessful. The Medical Director stated that, although she did not feel the resident would have suffered serious harm from receiving the medication outside the parameter, she expected nursing staff to follow the blood pressure parameters as written. The DON also stated she expected staff to follow physician orders, including hold parameters for blood pressure medications, and reported she had recently assumed the role and was unaware that the medication had been administered outside the prescribed parameters.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.