Failure to Monitor Antihypertensive Medication as Recommended
Penalty
Summary
The facility failed to follow the pharmacist's recommendation for monitoring antihypertensive medication for a resident diagnosed with adult failure to thrive, cognitive communication deficit, congestive heart failure, and hypertension. The resident's medical record showed an order for Toprol XL, an antihypertensive medication, but there was no consistent documentation of heart monitoring in the Medication Administration Record, Treatment Administration Record, or electronic medical record over a period of 111 days. The care plan indicated that staff would administer medications as ordered, but did not address the lack of monitoring for the antihypertensive medication. Interviews with nursing staff confirmed that monitoring should occur when administering antihypertensive medications, and that clarification should be sought if physician orders lack specific parameters. The administrative nurse also acknowledged that the care plan should identify the need for correct medication monitoring. The facility was unable to provide a policy related to medication monitoring, further demonstrating the lack of appropriate oversight for residents receiving antihypertensive therapy.