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F0658
D

Failure to Obtain Blood Pressure Prior to Antihypertensive Administration

Pooler, Georgia Survey Completed on 07-02-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to follow professional standards of practice by not obtaining and documenting a blood pressure reading prior to administering a prescribed blood pressure medication to a resident diagnosed with hypertension. According to the physician's order, the medication Sotalol was to be held if the resident's systolic blood pressure was less than 110 or diastolic blood pressure was less than 70. However, review of the Medication Administration Record showed that the medication was administered multiple times without any documented blood pressure readings beforehand. Interviews with facility staff confirmed that the required blood pressure checks were not performed prior to medication administration. An LPN acknowledged not taking the resident's blood pressure before giving the medication and noted that the order was not correctly entered into the electronic record system, omitting the instruction to check blood pressure each time. The Regional Director of Nursing also confirmed that the nurse should have followed the physician's order to obtain the blood pressure prior to administering the medication.

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