Failure to Monitor Vital Signs as Ordered
Penalty
Summary
The facility failed to adhere to its policy and procedure for administering medications for one of the sampled residents, Resident 4. The licensed staff did not monitor Resident 4's blood pressure and heart rate every six hours as ordered by the resident's physician. This oversight was critical as Resident 4 had a history of hypertension, hemiplegia, type 2 diabetes mellitus, and end-stage renal disease, making them clinically compromised. The care plan for Resident 4 highlighted the risk for cardiac distress and required monitoring of vital signs to prevent unrecognized signs and symptoms of cardiac issues. Despite the physician's orders to administer Hydralazine as needed and monitor vital signs every six hours, the Medication Administration Record showed no recordings of blood pressure and heart rate from February 1 to February 17, except on February 18. The Licensed Vocational Nurse admitted to not checking the blood pressure every six hours, and the Director of Nursing confirmed that the staff was only conducting weekly blood pressure checks, contrary to the physician's orders. This failure resulted in Resident 4 being sent to the hospital for evaluation and treatment due to hypertension.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident 4 is no longer in the facility and was discharged 2/18/2025. On 3/5/2025, the DON initiated an in-service to the licensed staff regarding medication administration guidelines and procedures, emphasizing monitoring blood pressure for residents on anti-hypertensive medications as ordered by the physician. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. On 3/5/2025, DON/Designee conducted an order and MAR review of all residents on anti-hypertensive medications to ensure all residents with such orders have BP monitoring as ordered by the physician. No additional discrepancies were noted with the same deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur. The DON/designee will review new orders for anti-hypertensive medications weekly for 3 months to ensure all residents with orders have BP monitoring in place. How the facility plans to monitor its performance to make sure that solutions are sustained. Reporting and review of the above will occur monthly in QA Meeting with the QA Committee for 3 months.