Failure to Assess and Document Blood Pressure Prior to Administration of Antihypertensive Medications
Penalty
Summary
The facility failed to accurately administer blood pressure (BP) medications to two residents by not following physician orders and facility policy regarding assessment and documentation of vital signs prior to medication administration. For one resident with hypertensive heart disease, heart failure, and chronic kidney disease, multiple nurses did not assess or document BP immediately prior to administering carvedilol and nifedipine, as required by the medication orders which specified to hold the medication if systolic BP was less than 100 or heart rate was less than 60. Instead, nurses often relied on BP readings taken hours earlier or for unrelated assessments, such as COVID-19 screening, rather than obtaining a current BP immediately before giving the medication. Interviews with nursing staff confirmed that they sometimes used previous BP readings rather than checking at the time of administration, acknowledging the risk of adverse reactions if the resident's BP had changed since the last measurement. Another resident, with a history of hypotension, hypertensive heart disease, and end stage renal disease, was administered isosorbide mononitrate despite a BP reading of 92/54, which was below the ordered hold parameter of systolic BP less than 100. The nurse responsible for administering the medication stated that BP and heart rate should be checked prior to giving BP medications and that medications should be held if the parameters are not met. The Director of Nursing confirmed that the purpose of hold parameters is to prevent injury or hospitalization due to hypotension and that BP should be checked within a couple of minutes, but not more than an hour before or after medication administration. Review of the facility's policy and procedure on medication administration indicated that vital signs must be taken and medications held if indicated by the order. Despite this, documentation and interviews revealed that nurses did not consistently follow these requirements, resulting in medications being given without proper assessment or documentation of BP immediately prior to administration. This failure to follow established protocols and physician orders had the potential to cause harm to residents with complex medical conditions.