Failure to Document Vital Signs Prior to Medication Administration
Penalty
Summary
The facility failed to implement physician's orders for a resident with diagnoses including atrial fibrillation, chronic kidney disease, and hypertensive retinopathy. The physician had ordered that staff administer metoprolol tartrate twice daily, with instructions not to give the medication if the resident's heart rate was below 60 beats per minute or if systolic blood pressure was below 110 mm/Hg. Review of the resident's medication administration records for April and May 2025 showed that staff either administered or withheld the medication 86 times without documenting that heart rate and blood pressure were assessed prior to the decision, as required by the physician's order. The Director of Nursing confirmed that there was no documented evidence of these vital sign assessments prior to medication administration or withholding.