Failure to Document Blood Pressure Prior to Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate documentation and administration of blood pressure medication for a resident with multiple diagnoses, including low blood pressure and cerebral infarction. The resident had a physician's order for Midodrine with specific parameters to hold the medication if the systolic blood pressure was greater than 100. However, review of the medication administration record (MAR) showed no documentation of the resident's blood pressure results prior to administering the medication, as required by the physician's order. During medication administration, the certified medication aide (CMA) attempted to take the resident's blood pressure and administer the medication, but the resident refused both the blood pressure measurement and the medication. The CMA reported that she was aware of the medication parameters but did not document blood pressure results because there was no designated area in the electronic medical record to do so, and she had not communicated this issue to anyone. Interviews with other staff confirmed that blood pressure results were not being documented as required, despite facility policy stating that vital signs should be taken and recorded prior to medication administration when applicable.