Failure to Monitor Vital Signs Prior to Medication Administration
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary drugs by not adhering to physician orders regarding the monitoring of vital signs prior to medication administration. For one resident prescribed Carvedilol for hypertension, the physician's order required holding the medication if the heart rate was less than 50, but there was no documentation that heart rate was consistently monitored before administration. Similarly, another resident receiving Hydralazine for hypertension had an order to hold the medication if systolic blood pressure was less than 110, yet the medication was administered when the blood pressure was 100/62. In both cases, the Director of Nursing confirmed that the required monitoring was not performed as ordered. A third resident, with a history of orthostatic hypotension, was prescribed Midodrine with specific parameters to hold the medication if blood pressure exceeded certain thresholds. The medication was administered multiple times outside of these parameters, as documented in the Medication Administration Records. Interviews with nursing staff and the Director of Nursing confirmed that medications were given even when vital signs were outside the prescribed limits, and that the required monitoring and documentation were not consistently performed.