Failure to Notify Provider of Held Antihypertensive Medication and Omission of Pre-Transfer Vital Signs
Penalty
Summary
A resident with multiple complex medical conditions, including heart failure, hypertension, diabetes mellitus, respiratory failure, and acute pyelonephritis, was admitted to the facility and later discharged to the hospital. The resident had an active order for Amlodipine Besylate 5 mg daily for hypertension, with instructions to monitor vital signs every shift. On two occasions, the resident's blood pressure medication was held due to low blood pressure readings, but there was no documentation that the provider was notified of the held medication as required by facility policy. Additionally, prior to the resident's transfer to the hospital, vital signs were not obtained and documented, which limited the provider's ability to assess the resident's condition before hospitalization. Interviews with nursing staff and the DON confirmed that the facility's process requires obtaining vital signs before administering blood pressure medication and before hospital transfer, and that the provider should be notified when medications are held. However, review of the medical record and interviews revealed that these steps were not followed in this case. Facility policy on medication administration and transfer/discharge requires medications to be administered as prescribed and for appropriate documentation and communication during transfers. The DON confirmed the absence of documentation regarding provider notification for the held medication and acknowledged that vital signs were not obtained prior to the resident's hospital transfer, as required by facility procedures.