Failure to Accurately Document Blood Pressure Re-Check and Medication Hold
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident with multiple diagnoses, including acute on chronic diastolic heart failure, type 2 diabetes mellitus, hyperlipidemia, hypertension, and atrial fibrillation. On a specific date, a medication aide held the resident's prescribed Metoprolol succinate due to a low blood pressure reading of 101/34, as per physician orders to hold the medication if systolic blood pressure was less than 110 or pulse less than 60. The aide notified the charge nurse, who then re-checked the blood pressure manually and recalled it being higher, possibly 115/58, and stated she notified the nurse practitioner as per protocol. However, the charge nurse did not document the re-checked blood pressure or the notification to the nurse practitioner in the resident's nursing notes. The nurse admitted to forgetting to document this information, having written it on another paper instead. The facility's policy requires that each resident's medical record contain an accurate and complete representation of the resident's experiences, including timely documentation. This lapse resulted in incomplete and inaccurate medical records for the resident.