Failure to Assess and Document Vital Signs Prior to Medication Administration
Penalty
Summary
The facility failed to follow physician's orders regarding medication administration for one resident. According to the facility's medication administration policy, medications must be given in accordance with written physician orders, and documentation in the electronic medication administration record (E-MAR) should include vital signs such as blood pressure or heart rate when appropriate. For a resident who was cognitively intact, independent with personal care, and had a diagnosis of diabetes, physician's orders specified that amlodipine should be held for a systolic blood pressure (SBP) less than 120, clonidine should be held for SBP less than 120 or heart rate less than 55, and metoprolol should be held for SBP less than 100 or heart rate less than 55. Review of the resident's E-MAR for the relevant months showed no documented evidence that blood pressure or heart rate was checked prior to administering amlodipine, clonidine, or metoprolol as ordered. The Director of Nursing confirmed that these assessments should have been performed and documented prior to medication administration, but they were not. This failure to assess and document vital signs prior to administering these medications constituted a deficiency in following physician's orders and facility policy.