Failure to Monitor Blood Pressure Parameters Before Administering Antihypertensive Medications
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs by not following physician-ordered parameters for blood pressure monitoring prior to administering antihypertensive and related medications. The resident, who had diagnoses including atrial fibrillation, hypertensive chronic kidney disease, edema, and congestive heart failure, was prescribed several medications with specific instructions to hold administration if systolic blood pressure (SBP) was below 100 or if heart rate was below 50. Despite these orders, medication administration records (MARs) for multiple months showed that the medications were given without consistent documentation of SBP or heart rate prior to administration. Review of the resident’s care plan and physician orders indicated that vital signs were to be checked every shift while the resident was on skilled care, and that medications such as Amlodipine, Furosemide, Losartan, and Carvedilol were to be held based on specific blood pressure and heart rate parameters. However, MARs and blood pressure summaries revealed that vital signs were not consistently documented before medication administration, and in many instances, there was no record of the required monitoring. Interviews with nursing staff confirmed that while they were aware of the need to check vitals and hold medications as ordered, the documentation was incomplete or missing in the electronic medical record (EMR). The Director of Nursing acknowledged that medication orders should be followed and that parameters for holding medications must be adhered to, but confirmed that regular vital checks prior to administration were not documented for this resident. The lack of adherence to prescribed monitoring protocols and incomplete documentation led to the administration of medications without ensuring the resident met the required parameters, constituting a failure to prevent unnecessary drug administration.