Failure to Accurately Document and Administer Blood Pressure Medication per Physician Parameters
Penalty
Summary
A deficiency occurred when staff failed to administer blood pressure medication according to physician-ordered parameters for a resident with diagnoses including atrial fibrillation, malignant prostate cancer, and pneumonia. The physician's order specified that Diltiazem 120 mg should be withheld if the resident's systolic blood pressure was less than 110. During observation, an LPN withheld the medication when the resident's blood pressure was 104/66 and disposed of the dose in the sharps container. However, the Medication Administration Record (MAR) for that day showed that the LPN signed off as if the Diltiazem had been administered, and there was no documentation of a blood pressure recheck. The Director of Nursing confirmed the discrepancy between the MAR and the actual administration, as well as the lack of required documentation. Facility policy required medications to be administered as ordered by the physician, which was not followed in this instance.