Failure to Administer Medications and Monitor Vital Signs per Physician Orders
Penalty
Summary
A resident with diagnoses of paroxysmal atrial fibrillation and acute on chronic combined systolic and diastolic heart failure did not receive treatment and care in accordance with professional standards of practice. Physician orders required administration of Diltiazem and Carvedilol for hypertension, with specific parameters to hold the medications if systolic blood pressure was less than 100 or pulse was less than 60. The resident's medical record showed that Carvedilol was last administered at 9 a.m. and Diltiazem at 1 p.m. on the day prior to the resident being found unresponsive. Blood pressure was last checked at 11:09 a.m. and pulse at 6 p.m., with the pulse noted to be elevated at 103 beats per minute. There was no documentation explaining why the afternoon doses of Carvedilol and Diltiazem were not given, nor why vital signs were not checked in the afternoon. The Director of Nursing confirmed during interview and record review that the lack of documentation for missed medication administration and vital sign monitoring was not in accordance with facility policy. Facility policies required that vital signs be obtained as appropriate and that all medications administered, as well as procedures and treatments, be documented in the resident's medical record, including reasons for refusal or omission. The failure to follow these protocols resulted in a deficiency related to providing treatment and care according to orders and professional standards.