Inaccurate Medication Administration Documentation for Antihypertensive Therapy
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for one resident reviewed for unnecessary medication use. The resident, who had multiple diagnoses including congestive heart failure, hypertension, dementia, diabetes, and a history of stroke, was prescribed Hydralazine for hypertension with specific instructions to hold the medication if the systolic blood pressure (SBP) was less than 130. Despite this, the Medication Administration Record (MAR) documented that Hydralazine was administered on several occasions when the resident's SBP was below the threshold specified in the physician's order. Interviews with nursing staff revealed that the medication was not actually given on those occasions, and the inaccurate documentation was attributed to errors in the electronic health record system. The Interim Director of Nursing confirmed that blood pressure medications should be held according to physician orders and that accurate documentation is essential. Additionally, the facility's policy provided did not specifically address the need for accuracy in medical record documentation.