Failure to Document Blood Pressure Prior to Medication Administration
Penalty
Summary
The facility failed to ensure complete and accurate documentation of specified assessment criteria for a resident receiving medication with blood pressure (BP) parameters. A resident with multiple diagnoses, including hypertension and peripheral vascular disease, had a physician order for Carvedilol to be administered twice daily, with instructions to hold the medication if systolic BP was less than 130. During medication administration observation, the nurse did not document the BP prior to giving the medication, and the last recorded BP in the medical record was several days prior. There was no evidence in the medical record that BP was checked and met the ordered parameters before each dose, as required by the medication order. Further review revealed that the medication administration record (MAR) did not prompt or provide a place for nurses to document BP readings before each Carvedilol dose, only requiring monthly vital signs. Interviews with nursing staff confirmed that BPs were typically checked before administration but not documented in the electronic medical record, and any written notes were discarded. The Assistant Director of Nursing confirmed the lack of documentation and that nursing administration was not informed of the issue prior to the survey. Facility policy required documentation of services and objective observations in the resident's medical record, which was not followed in this case.