Failure to Check Heart Rate Before Administering Cardiac Medications
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to check a resident's heart rate prior to administering Hydrochlorothiazide and Verapamil, both of which were ordered with specific parameters to hold the medication if the systolic blood pressure was less than 110 or the heart rate was less than 60. During a medication pass observation, the LVN checked the resident's blood pressure but did not check the heart rate before preparing and attempting to administer the medications. The surveyor intervened and questioned the LVN, who then acknowledged forgetting to check the heart rate and confirmed that the physician's order required it. The resident involved had diagnoses including atherosclerotic heart disease, hypertension, and a history of falls, with intact cognition and the capacity to make decisions. Facility policy and procedures reviewed by the Director of Nursing (DON) indicated that medications must be administered according to physician orders, including taking vital signs such as heart rate and blood pressure when required. The failure to follow these procedures and physician orders constituted a significant medication error as defined by the facility's policies.