Failure to Monitor Vital Signs Before Administering Cardiovascular Medications Resulted in Harm
Penalty
Summary
A deficiency occurred when a resident with a history of cardiovascular issues, including a prior non-ST elevation myocardial infarction and essential hypertension, was not adequately monitored before administration of multiple cardiovascular medications. The resident's care plan required monitoring of vital signs and holding medications if certain parameters, such as a low pulse, were met. On the evening prior to the incident, the resident's pulse was recorded as 57 beats per minute, leading to the appropriate withholding of Metoprolol as per the medication order. However, blood pressure was not assessed at that time. The following morning, the resident's pulse was 70 beats per minute, but again, blood pressure was not measured prior to administering four cardiovascular medications, including Metoprolol, Isosorbide Mononitrate ER, Amlodipine Besylate, and Lisinopril. The medication order for Metoprolol specified to hold the medication if the pulse was less than 60, but there were no parameters for blood pressure, and no blood pressure reading was taken before administration. Shortly after receiving the medications, the resident became unresponsive, with a significant drop in both pulse and blood pressure. The resident was transported to the emergency room, where she was treated for hypotension with intravenous fluids. Documentation and interviews revealed that the facility did not have protocols in place for routine blood pressure or pulse monitoring for residents receiving blood pressure medications, unless specific parameters were listed in the medication orders. This lack of monitoring and protocol contributed to the adverse event, as the resident experienced actual harm due to the administration of medications without adequate assessment of vital signs.