Failure to Monitor and Document Vital Signs for Residents on Antibiotics and Antihypertensives
Penalty
Summary
The facility failed to monitor and document vital signs, specifically temperatures and blood pressures, for residents receiving antibiotics for respiratory infections and antihypertensive medications as required by facility policy and physician orders. For two residents being treated with antibiotics for respiratory infections, there was no documentation of temperatures during the course of their treatment, despite physician orders and facility policy requiring daily monitoring of vital signs for residents receiving skilled services. Staff interviews confirmed that temperatures were not checked or documented, even though the residents were actively being treated for infections and staff were aware of the importance of monitoring temperature in these cases. One resident with no cognitive impairment was prescribed Levaquin for a cough, but the last documented temperature was over a month prior to the start of antibiotic therapy. Staff acknowledged that temperatures had not been checked or recorded during the treatment period, and progress notes referenced the absence of fever without supporting documentation. Another resident with severe cognitive impairment and a history of pleural effusion and acute asthma was also prescribed Levaquin for pneumonia, but there was no documentation of temperature checks during the antibiotic course, with the last recorded temperature predating the start of treatment. Additionally, a third resident with multiple complex medical conditions, including ventilator dependence and hypertension, had physician orders for Enalapril with specific blood pressure parameters. However, there was no documentation of blood pressure readings in the Medication Administration Record (MAR) at the times the medication was administered on several dates. Staff interviews confirmed that the medication was given, but the required blood pressure monitoring was not documented as per policy and physician orders.