Failure to Monitor Vital Signs Before Administering Heart Medication
Penalty
Summary
The facility failed to ensure adequate monitoring of vital signs as required by physician's orders prior to administering a medication that affects heart rate and rhythm for one resident. The resident, who had diagnoses including dementia, Parkinson's disease, and atrial fibrillation, was prescribed digoxin with instructions to check the pulse before administration and to hold the medication if the pulse was less than 60 beats per minute. Review of the Medication Administration Record for April and May 2025 showed no documentation of the resident's heart rate at the time of digoxin administration, although the medication was marked as given daily. The Director of Nursing confirmed that the order was implemented upon the resident's readmission, but the requirement to document the heart rate with each administration was not communicated to the nursing staff.