Failure to Obtain Timely Vital Signs Before Administering Anti-Hypertensives
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically for two residents who were administered anti-hypertensive medications without proper assessment of their vital signs immediately prior to administration. Medication Aide B administered Amlodipine to both residents, and Losartan and Carvedilol to one resident, using blood pressure and pulse readings that had been obtained approximately 1.5 to 2 hours before the medication pass, rather than immediately before as required by physician orders and facility policy. Observations confirmed that the medication aide did not check the residents' blood pressure and pulse at the time of medication administration. One resident had a history of stroke, hypertension, heart disease, and other chronic conditions, and was ordered to receive Amlodipine with specific parameters to hold the medication if blood pressure or heart rate fell below certain thresholds. The other resident, with diagnoses including stroke, dementia, hypertension, and peripheral vascular disease, was ordered to receive multiple anti-hypertensive medications with similar hold parameters. In both cases, the medication aide relied on early morning vital signs rather than obtaining current readings, as confirmed by documentation and direct observation during the medication pass. Interviews with the medication aide, other nursing staff, the Director of Nursing, and the Medical Director revealed a consensus that blood pressure and pulse should be checked immediately prior to administering anti-hypertensive medications, in accordance with physician orders and best practice. The facility's policy also required vital signs to be obtained and recorded when applicable or per physician orders, specifically for medications requiring such monitoring. The failure to follow these procedures resulted in significant medication errors for the two residents reviewed.