Failure to Follow Physician Orders for Blood Pressure Monitoring and Medication Hold Parameters
Penalty
Summary
The facility failed to follow physician orders and medication hold parameters for two residents. For one resident with a history of hypertension, diabetes, mood disorder, dementia, psychosis, and benign intracranial hypertension, there were documented gaps in weekly blood pressure monitoring as ordered by the physician. The resident's care plan required weekly blood pressure checks and documentation, but the facility was unable to provide records of these checks for several months, coinciding with a transition to an electronic medical record system. This lack of documentation was confirmed by the MDS coordinator. For another resident with hypertension and moderate cognitive impairment, the facility did not adhere to the physician's order to hold Carvedilol if the systolic blood pressure was less than 120. The medication administration record showed multiple instances where the medication was given despite systolic blood pressure readings below the specified threshold. Both the ADON and a CMA acknowledged that the medication should have been held according to the order, but it was administered regardless.