Failure to Check Blood Pressure Before Administering Furosemide
Penalty
Summary
Facility staff failed to follow professional standards of quality by not checking a resident's blood pressure prior to administering a prescribed dose of Furosemide 20 mg. The physician's order and the resident's care plan both required that blood pressure be monitored and the medication be held if the systolic blood pressure was less than 100. On the specified date and time, an LPN administered the medication without first checking the resident's blood pressure, as confirmed by direct observation and subsequent staff interview. The vital signs record also showed no blood pressure reading was taken at or around the time of medication administration. The resident involved had a history of acute or chronic diastolic congestive heart failure and was at risk for decreased cardiac output, with a care plan goal to maintain vital signs within normal limits. The resident's cognitive abilities were severely impaired, as indicated by a low BIMS score. Despite these factors and clear orders, the required assessment was omitted before giving the medication, constituting a failure to meet professional standards of care.