Failure to Monitor and Document Vital Signs After Medication Discontinuation
Penalty
Summary
A deficiency occurred when the facility failed to obtain and document vital signs according to a provider order for a resident who required monitoring after the discontinuation of a blood pressure medication. The resident, who had multiple sclerosis, functional quadriplegia, neurogenic bladder, and a pressure ulcer, was identified as having intermittent hypotension and had their metoprolol succinate discontinued. The provider ordered that vital signs be obtained every shift following this change. However, review of the medical record revealed that vital signs were not recorded for several specified shifts. Interviews with staff indicated that nursing assistants were responsible for obtaining vital signs, which were then to be reviewed and entered into the electronic medical record by the assigned nurse. The LPN assigned to the resident during the missed shifts could not recall if she had reviewed the vital signs and did not know why they were not recorded. The APRN confirmed the importance of monitoring vital signs after discontinuing the medication, and the DNS stated that nurses are expected to follow provider orders. The facility did not provide a policy for obtaining vital signs when requested.