Failure to Monitor High-Risk Medication and Address Syncopal Episodes
Penalty
Summary
The facility failed to ensure safe monitoring practices for a high-risk medication, metoprolol, prescribed to a resident with a history of atrial fibrillation and hypertension. The medication order did not include parameters for when to hold or administer the drug based on the resident’s blood pressure (BP) or heart rate (HR). Multiple instances of abnormal BP and HR readings were documented, but there was no evidence that these results were reviewed with the resident’s physician or that the medication order was clarified to include necessary monitoring parameters. The consultant pharmacist also confirmed that recommendations for daily monitoring should have been made, but he was not notified of the resident’s syncopal episodes or abnormal vital signs during his reviews. The resident experienced multiple syncopal episodes, particularly during transfers using a standing lift, which were not consistently reported by the certified nursing assistant (CNA) to the licensed nurse (LN). When episodes were documented, there was no evidence that the resident was assessed for orthostatic hypotension or that orthostatic BP and HR checks were performed. Several LNs acknowledged during interviews that further assessment and monitoring should have occurred, and that the physician should have been notified to provide more accurate medication parameters. However, these actions were not taken, and the episodes were not communicated to the consultant pharmacist or the physician in a timely manner. The Director of Nursing (DON) was unaware of the frequency of the resident’s syncopal episodes and only became aware of one such event. Upon review, the DON acknowledged that the resident’s fluctuating BP and HR, combined with a history of syncope, warranted holding the medication, performing orthostatic checks, and notifying the physician. The facility’s policy required physician notification and inclusion of parameters for abnormal BP and HR, but these procedures were not followed, resulting in a failure to ensure safe medication administration and monitoring for the resident.