Failure to Document Vital Signs Prior to Medication Administration
Penalty
Summary
A deficiency was identified when a resident with a diagnosis including hypertension was not provided care in accordance with professional standards and physician's orders. The resident had physician orders for Metoprolol Succinate ER 50 mg daily, with specific instructions to hold the medication if the systolic blood pressure (SBP) was less than 100 or if the apical pulse (AP) was less than 60 (later changed to less than 50). These orders were in effect from late April through early July 2025. Record review of the Medication Administration Records (MAR) for April, May, June, and July 2025 did not show documentation that the resident's blood pressure or apical pulse were checked prior to administering the medication as required. During interviews, both a registered nurse and the Director of Nursing Services confirmed that there was no evidence that these vital signs were obtained before medication administration, as directed by the physician's orders.