Failure to Assess and Document Vital Signs Prior to Antihypertensive Medication Administration
Penalty
Summary
The facility failed to ensure that a resident's blood pressure and pulse were assessed and documented prior to the administration of hydralazine and lisinopril, as required by physician orders and the resident's care plan. The resident, who had diagnoses including hypertensive heart disease, chronic pulmonary edema, and schizophrenia, was admitted with specific medication orders that required holding the blood pressure medications if the systolic blood pressure was less than 110 mm Hg or the pulse was less than 60 beats per minute. Despite these clear parameters, the electronic medication administration record (eMAR) and vital signs summary showed no documentation of blood pressure or pulse measurements prior to medication administration on multiple occasions. Interviews with the DON and an LVN revealed that the lack of documentation was due to the LVN's failure to input the necessary supplemental documentation fields in the eMAR, which prevented nurses from recording the required vital signs before administering the medications. As a result, there was no evidence that the resident's vital signs were checked as ordered, and the medications were administered without the necessary assessments. Facility policies and job descriptions reviewed indicated that comprehensive care planning and proper medication administration and documentation were required, but these were not followed in this instance.