Failure to Accurately Document Blood Pressure Prior to Administration of BP-Altering Medications
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for two residents who were receiving blood pressure-altering medications. Licensed vocational nurses (LVNs) did not consistently document blood pressure readings as required by physician orders and facility policy prior to administering medications such as amiodarone, hydralazine, metoprolol, midodrine, and amlodipine. In multiple instances, the same blood pressure readings were documented for several medication administrations in a row, which is not consistent with normal physiological variation and suggests that actual measurements may not have been taken each time. For one resident with diagnoses including chronic heart failure, hypertension, hypotension, and end-stage renal disease, LVNs failed to correctly document blood pressure readings on numerous occasions when administering medications that required such monitoring. The electronic medication administration record (eMAR) often showed repeated or identical blood pressure values for different times and dates, and in some cases, there were no corresponding entries in the blood pressure summary. Interviews with staff revealed that at times, blood pressure values were copied from previous entries if the nurse misplaced the original documentation, rather than being measured and recorded at the time of medication administration. Another resident with hypertension and chronic kidney disease also had repeated blood pressure values documented for consecutive days when receiving antihypertensive medication, with missing entries in the blood pressure summary. Staff interviews confirmed that the practice of documenting without actual measurement occurred, and that this was not in accordance with facility policy or physician orders. The facility's own guidelines required blood pressure to be checked and documented immediately prior to administration of such medications, but this was not consistently followed.