Failure to Monitor Blood Pressure Prior to Medication Administration
Penalty
Summary
A deficiency occurred when a nurse failed to check a resident's blood pressure prior to administering furosemide, as required by the physician's order. The facility's policy and the physician's order both specified that blood pressure should be monitored before giving the medication, with instructions to hold the dose if the systolic blood pressure was below 100 or diastolic below 60. During a medication pass, the LPN prepared and administered the resident's medications, including furosemide, without obtaining a current blood pressure reading. The last recorded blood pressure in the resident's chart was from several days prior, and the nurse acknowledged during an interview that the check should have been performed immediately before administration. The resident involved had a medical history including diabetes, major depressive disorder, cerebrovascular disease, and edema, and was receiving furosemide for edema management. Both the DON and the resident's physician confirmed that blood pressure monitoring was expected before administering the medication, in accordance with the physician's order and facility policy. The physician noted that while the resident's blood pressures had been stable and no recent low readings had been reported, the standard practice should have been followed.