F0757

D

Failure to Follow Ordered Vital Sign Parameters for Antihypertensive Medication

Logan, Ohio Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The facility failed to ensure a resident’s drug regimen was free from unnecessary drugs by not following physician-ordered parameters for administration of Metoprolol Tartrate. The resident, admitted with diagnoses including cerebral infarction, unspecified and unspecified asthma, uncomplicated, had a physician order dated 01/30/26 for Metoprolol Tartrate 25 mg, 1.5 tablets by mouth twice daily for HTN, with instructions to hold the medication if systolic blood pressure (SBP) was below 110 or heart rate (HR) was below 60. Review of the medication administration record showed no documented SBP or HR from 01/30/26 through 02/26/26, despite the order requiring these parameters to determine whether the medication should be given or held. Pharmacy reiterated the same hold parameters on 02/26/26, yet vital signs were still not documented for the earlier period, and staff interviews confirmed that the medication should have been held for specific doses on 03/10/26 and 03/11/26 but was not. Review of the facility’s Medication Administration Policy dated 08/22/22 showed that staff were required to obtain and record vital signs when applicable or per physician orders and to hold medications when vital signs fell outside prescribed parameters, which was not followed in this case.

This deficiency was identified for one resident out of five reviewed for unnecessary medications, with a facility census of 92, and was investigated under Complaint Number 2696141.