Failure to Obtain Apical Pulse Prior to Digoxin Administration
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to obtain an apical pulse prior to administering digoxin to a resident. The resident, who had a history of cerebral infarction, hypertension, and atrial fibrillation, had a physician's order for digoxin with specific instructions to notify the provider if the heart rate was less than 40 beats per minute. During medication administration, the RN used an electronic machine to obtain the resident's vital signs and associated the pulse from the machine with the administration of digoxin, rather than obtaining an apical pulse as required. When questioned, the RN admitted to not obtaining an apical pulse before administering the medication. The Director of Nursing (DON) later confirmed that an apical pulse should be obtained prior to administering digoxin. The failure to follow this protocol resulted in a significant medication error for the resident observed during the medication pass.