F0760

E

Failure to Follow BP Medication Hold Parameters and Document Administration

Pasadena, Texas Survey Completed on 03-18-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in medication administration related to blood pressure medications for two residents. For the first resident, an older female with multiple diagnoses including cerebral infarction, peripheral vascular disease, hypertension, heart failure, chronic kidney disease, atrial fibrillation, chronic embolism/thrombosis, and COPD, the physician’s order dated 9/8/2025 directed Metoprolol Tartrate 25 mg by mouth twice daily for hypertension, to be held if systolic blood pressure (SBP) was less than 110, diastolic blood pressure (DBP) less than 60, or heart rate less than 60. Review of the March 2026 MAR showed that on 3/9/2026, when her blood pressure was 106/70, Metoprolol 25 mg was not documented as held, and there was no code indicating refusal or that the resident was not in the facility.

For the second resident, an older female with diagnoses including depression, anemia, hyperlipidemia, cerebral infarction, hypotension, acute respiratory failure, and type 2 diabetes, a physician’s order dated 2/27/2026 directed Midodrine HCL 10 mg by mouth three times a day, to be held if SBP was greater than 120 or heart rate was greater than 60. Review of her March 2026 MAR showed that Midodrine 10 mg was not documented as held on multiple occasions when her vital signs were outside the ordered parameters: on 3/2/2026 with BP 137/73 and HR 75, on 3/3/2026 with BP 133/63 and HR 78 at 9:00 p.m., and on 3/5/2026 at 3:00 p.m. with BP 124/76 and HR 85.

Multiple staff interviews, including LVNs, a med aide, and the DON, confirmed that there should be no blanks on the MARs and that if medications were given or not given, including refusals or residents being out of the building, this must be documented. Staff stated that blanks on the MAR indicate medications were not given and that blood pressure medications should be held or administered according to physician-ordered parameters. The facility’s Charting and Documentation policy dated July 2017 stated that all services and treatments, including whether a resident refused a procedure or treatment, must be documented in the medical record, with the signature and title of the individual documenting. Despite these expectations and policies, the MARs for both residents contained blanks and lacked documentation that the ordered hold parameters for Metoprolol and Midodrine were followed.