HospitalInspections.org

Based on interview and record review, the facility failed to ensure that medications were administered per order for one (1) of eleven (11) sampled patients (ID #6).


Findings include:


Review of facility policy titled "Medication Management: Medication Administration," dated 8/20/21, stated "Purpose: ... establish the process for administering medications and it pertains to all areas of the hospital that administers medicines. Procedure: Compliance with medication orders: Medications shall be prepared and administered in accordance with the orders if the prescriber or practitioner responsible for the patient's care and accepted standards of practice."


Medical Record Review for patient (ID #6) showed the following information:
Medication order Metoprolol tartrate 50 MG, Give 50 mg (1 tablet) by mouth Twice a day. HOLD if systolic blood pressure (SBP) <110 AND heart rate (HR) < 60.

Medication Administration record for patient (ID#6) on 10/13/2020 at 0904 showed Metoprolol 50 mg dose was HELD due to BP. Documented vital signs for patient (ID# 6) on 10/13/2022 at 0904 were BP 115/72 (SBP > 110) and HR 100 b/min (>60)


Interview on 10/20/2022 with Chief Nursing Officer at 1300 (ID# 52), she stated that medications were expected to be administered per physician order. There was no documentation to support the medication dose to be held. Patient (ID #6) should have received the medication as ordered based on vital signs documented for the patient (ID# 6).