Failure to Document Blood Pressure Prior to Antihypertensive Administration
Penalty
Summary
A resident with a history of epilepsy, aphasia, and nontraumatic intracerebral hemorrhage was prescribed amlodipine for hypertension, with physician orders specifying that the medication should be held if the diastolic blood pressure was less than 110 mmHg or the systolic blood pressure was less than 60 mmHg. The resident's care plan included interventions to obtain and record blood pressure readings under consistent conditions before administering antihypertensive medications. However, review of the Medication Administration Records for May and June showed that the resident received amlodipine 42 times without documentation of blood pressure readings at the time of administration. The Blood Pressure Vitals Record indicated that blood pressure was only recorded five times during this period, despite daily administration of the medication. Interviews with the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN) revealed that the electronic health record may not have prompted staff to input blood pressure readings prior to medication administration. The LVN stated she checked the resident's blood pressure before giving the medication but could not provide evidence of this in the records. The facility's medication administration policy required verification of vital signs when necessary prior to administering medications, but this was not consistently documented or followed in this case.