Failure to Monitor and Document Vital Signs for Cardiac Medication
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by not monitoring and documenting required blood pressure and heart rate parameters for a resident receiving Metoprolol Tartrate. The resident, who had diagnoses including ischemic heart disease, hypertensive heart disease with heart failure, and congestive heart failure, was prescribed Metoprolol with specific instructions to hold the medication if the heart rate was less than 60 or systolic blood pressure was greater than 110. Review of the Medication Administration Records for two months showed the medication was administered as ordered, but there was no documentation of the resident's heart rate or blood pressure at the time of administration. Interviews with the Director of Nursing and Assistant Director of Nursing confirmed that these parameters should have been documented and that a clarification order was needed for the blood pressure parameter.