Failure to Document Vital Signs on Admission and Before Antihypertensive Administration
Penalty
Summary
The facility failed to obtain and document vital signs upon admission and prior to administering a blood pressure medication for one resident. According to the facility's policy, vital signs should be recorded in the resident's medical record upon admission. The resident, who was cognitively intact, was admitted and subsequently discharged on the same day. Physician orders required blood pressure monitoring prior to administering antihypertensive medication, specifically Metoprolol, and directed staff to notify the physician if systolic blood pressure was less than 100. However, review of the electronic medical record and medication administration record showed that the resident received Metoprolol without any documentation of vital signs, including blood pressure or pulse, at admission or before medication administration. Interviews with nursing staff, including a registered nurse, an LPN, a residential care manager, and the DON, confirmed that the facility's practice is to obtain and document vital signs for new admissions and before administering blood pressure medications. Staff described a process where vital signs are initially recorded on a sheet and then entered into the electronic medical record. Despite this, all interviewed staff were unable to locate any documentation of the resident's vital signs in the electronic medical record for the relevant period, confirming the deficiency.