Medication Transcription Error Leads to Incorrect Metoprolol Dose
Penalty
Summary
The facility failed to ensure that metoprolol was administered according to physician orders for one resident. The resident was re-admitted in February 2026 with hypovolemic shock and muscle weakness, and had an MDS BIMS score of 13/15, indicating intact cognitive function. Hospital physician orders dated 2/18/26 directed that the resident was to receive metoprolol 100 mg twice daily. However, when the orders were transcribed into the facility’s electronic medical record on 2/18/26, the metoprolol dose was incorrectly entered as 200 mg to be given twice daily. The resident’s MAR for 2/18/26 reflected the incorrect order, stating “Metoprolol 100 mg, give 200 mg two times a day,” and documented that one 200 mg dose was administered on 2/19/26 at 8 a.m. An LPN confirmed administering the 200 mg dose, and another LPN acknowledged making a medication error during transcription of the hospital physician orders by entering 200 mg instead of 100 mg twice daily. The NP stated the resident was supposed to receive 100 mg twice daily and that an incorrect dose could further exacerbate the resident’s low blood pressure and lead to dizziness or a fall. The DON confirmed that the metoprolol order had been transcribed incorrectly and stated that nursing staff should enter physician orders as written. Facility policies required that documentation in the medical record be complete and accurate and that medications be administered in accordance with prescriber orders.
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