Failure to Document Blood Pressure Prior to Antihypertensive Administration
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident, specifically for two residents reviewed for medication administration. For one resident, there were twelve occasions in July when blood pressure was not obtained or documented prior to the administration of physician-ordered antihypertensive medication with specific parameters. The medication was either not administered or marked as not available, but no blood pressure readings or vitals were recorded on the Medication Administration Record (MAR) or in nursing progress notes for those times. Another resident experienced similar issues, with blood pressure not obtained or documented prior to the administration of physician-ordered antihypertensive medications twelve times in August and seven times in September. The MAR reflected that medications were not administered or marked as not available, but again, no blood pressure readings or vitals were recorded for those administration times. Nursing progress notes for these periods also lacked corresponding blood pressure readings when medications were held. Interviews with staff revealed that facility policy required blood pressure to be checked and documented prior to administering medications with parameters, and that reasons for withholding medications should be documented in the MAR and progress notes. Staff acknowledged that sometimes documentation was missed due to being busy, and that the electronic charting system did not always enforce entry of vitals when medications were skipped. The facility's policy also required notification of the physician when a dose was not given, but this was not consistently documented.