Deficiencies in Blood Pressure Monitoring and Antibiotic Administration
Penalty
Summary
The facility failed to ensure that a blood pressure apparatus was used in accordance with the manufacturer's specifications. During an observation, a Licensed Practical Nurse (LPN) attempted to take a resident's blood pressure multiple times using incorrect techniques, such as placing the cuff on the forearm instead of the upper arm and positioning the rubber tube on the outside of the arm. These errors resulted in repeated error readings. The Registered Nurse/Unit Manager (RN/UM) later confirmed the incorrect technique and stated that the LPN would be educated on the proper use of the device. Additionally, the facility did not administer an antibiotic treatment as ordered by the physician for a resident with a stage 4 pressure ulcer. The resident reported that there were days when the prescribed Gentamicin was not administered. A review of the electronic Medication Administration Record (eMAR) confirmed that doses on two separate days were missed. The facility's policy did not require notifying the physician unless two consecutive doses were missed, but the Director of Nursing acknowledged that the physician should have been informed of the missed doses. The report highlights deficiencies in both the administration of medication and the use of medical equipment, which were not in accordance with professional standards of practice. The facility's failure to adhere to these standards resulted in improper care for the residents involved, as evidenced by the incorrect blood pressure readings and the missed antibiotic doses.
Plan Of Correction
Based on observation, interview, and record review, it was determined that the facility failed to ensure a.) blood pressure apparatus was utilized in accordance with the manufacturer's specifications, b.) an antibiotic treatment was administered as ordered by the physician, and in accordance with professional standards of practice. This deficient practice was observed during the medication pass observation of 1 of 5 nurses who administered to 1 of 6 residents (Resident #20) and identified for 1 of 1 resident investigated for abuse (Resident #16). 1. Corrective Actions Accomplished for residents found to have been affected by the deficient practice: "Resident #20 [R] was taken using the correct method as per manufactures specification. Resident #20 was not affected by the deficient practice. 'US FOIA (b)(6) was educated immediately about proper use of NJ Ex apparatus by unit manager. "Resident #16 was not affected by deficient practice. MD was notified of missed treatments. No new orders were given. "Education was completed by the Director of Nursing with US FOIA (b)(6) regarding the process to be followed when medications are not available. "Medication administration policy was reviewed and updated to reflect communication of missed medication with the physician. 2. Identification of residents who have the potential to be affected by the same deficient practice: "All residents have the potential to be affected by the deficient practice. 3. Systemic changes to ensure that the deficient practice does not recur: "Education was provided by the Director of Nursing to all nursing staff regarding proper placement of blood pressure cuff. "Education was provided by the Director of Nursing to all nursing staff regarding the process to be followed when medications are not available and documenting communication with physician. "Blood Pressure cuff placement competency added to orientation and annual training. 4. Monitoring of corrective actions: "The Director of Nursing or designee will audit the placement of blood pressure cuff by 2 nurses weekly for 1 month and then monthly for 6 months. "The Director of Nursing or designee will audit 5 residents with treatment orders weekly for 1 month and then monthly for 6 months. "Results of the audit will be presented and reviewed during the quarterly Quality Assurance Performance Improvement (QAPI) meeting for 6 months, and additional corrective action will be implemented if deficiencies are identified.