Failure to Follow Physician Orders for Medication and Vital Sign Monitoring
Penalty
Summary
Staff failed to implement physician orders and monitor vital signs as required for a resident with multiple diagnoses, including paroxysmal atrial fibrillation and hypertension. The resident was prescribed Amiodarone with specific instructions to monitor blood pressure and heart rate twice daily and to hold the medication if the heart rate fell below a certain threshold, with notification to the cardiologist if the medication was held. However, review of the medical and medication administration records showed that vital signs were only monitored once daily instead of twice as ordered, and there was no documentation that the cardiologist was notified when the medication was held due to low heart rates on two occasions. Further review and staff interviews confirmed that the orders for vital sign monitoring were not properly entered into the medication or treatment administration records, resulting in the required monitoring not being completed. The Director of Nursing and an LPN both acknowledged that the medical record lacked evidence of physician notification and that the vital sign checks were not performed as ordered. The resident was severely cognitively impaired at the time, and the failure to follow physician orders and document required actions constituted the deficiency.