Failure to Monitor Antihypertensive Administration and Specify Topical Medication Dosage
Penalty
Summary
The facility failed to ensure appropriate monitoring and documentation for a resident receiving antihypertensive and topical pain medications. Specifically, staff did not obtain blood pressure or pulse readings prior to administering the beta blocker Carvedilol, as required for safe use of this medication class. The physician's order for Carvedilol lacked explicit instructions to monitor these vital signs before administration. Interviews with staff revealed uncertainty regarding which antihypertensive medications required such monitoring, and it was acknowledged by nursing leadership that monitoring should have occurred. Additionally, the facility did not ensure that physician orders for Voltaren gel, a topical pain medication, included clear dosage amounts for application to affected areas. Several orders for Voltaren gel were found to be incomplete, either lacking a specified dosage or omitting the amount to be applied to certain areas, such as the left shoulder. The facility's policy required that all medication orders include the dose and adequate monitoring, but this was not consistently followed for the resident in question, who had multiple complex diagnoses and required significant assistance with activities of daily living.