F0760

E

Failure to Assess Blood Pressure Prior to Metoprolol Administration

Portland, Texas Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors related to administration of an antihypertensive medication, Metoprolol. The resident was an [AGE]-year-old female with a diagnosis of essential primary hypertension, admitted on 02/24/2026 and discharged on 03/11/2026. A physician order dated 02/24/2026 directed Metoprolol 12.5 mg by mouth four times daily for hypertension, with instructions to hold the dose if the systolic blood pressure was less than 110 or the diastolic blood pressure was less than 60. The resident did not have a comprehensive care plan in place, and the March 2026 MAR reflected the Metoprolol order and administration times (9:00 AM, 12:00 PM, 5:00 PM, and 9:00 PM) but did not include corresponding blood pressure readings.

Record review of the resident’s vital signs showed that blood pressures were not taken at times that coincided with Metoprolol administration on multiple dates in February and March 2026, despite the order requiring blood pressure parameters prior to dosing. Specifically, there were no blood pressure measurements documented at the scheduled administration times on numerous dates between 02/25/2026 and 03/10/2026. The RNC was only able to locate a few blood pressure readings in the MAR and vital signs that coincided with the Metoprolol doses, and those readings were associated with another medication being administered, not with Metoprolol.

Interviews with facility staff confirmed that blood pressures should have been checked before administering the blood pressure medication. The NP stated that blood pressures should be checked prior to giving antihypertensive medications to determine if the resident actually needed the dose. The ADON stated that nurses should have checked blood pressures before administering the medication because it was required, and acknowledged that nurses had previously been in-serviced on this topic. The RNC and DON both stated that blood pressures should be assessed prior to administering blood pressure medications, and confirmed that only a few coinciding blood pressure readings could be found for this resident. The facility’s “Administering Medications” policy, revised April 2019, required that vital signs be checked or verified, if necessary, prior to administering medications, and external clinical guidance from the National Library of Medicine emphasized the importance of accurate blood pressure assessment for diagnosis and management of hypertension.