Failure to Document Blood Pressure Prior to Administration of Antihypertensive Medications
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration of blood pressure medications for two residents. For one resident with multiple diagnoses including hypertensive heart disease and atrial fibrillation, Carvedilol was prescribed with specific parameters to hold the medication if blood pressure was below 110/60 or pulse below 60. However, on nine occasions, there was no documentation that blood pressure was obtained prior to administering the medication, as required by the physician's order. Review of the resident's care plan also revealed no discussion of his blood pressure medication or related health condition. For another resident with diagnoses including Parkinson's disease and low blood pressure, Midodrine was prescribed with instructions to hold the medication if systolic blood pressure was greater than 120. On four occasions, there was no documentation of blood pressure readings prior to administration, and the care plan did not address the blood pressure medication or related condition. In both cases, review of the medication administration records and nursing progress notes did not show evidence that the required blood pressure checks were performed or documented before medication was given. Interviews with facility staff confirmed that it was standard practice to document blood pressure prior to administering such medications and to hold the medication if parameters were not met. Staff also indicated that the electronic charting system should prompt for blood pressure entry, but errors in order entry could bypass this requirement. Facility policy required monitoring and documentation of specific items such as blood pressure when ordered, but this was not consistently followed for the residents in question.