Failure to Monitor and Administer Antihypertensive Medication for New Admission
Penalty
Summary
The facility failed to provide necessary care and services to a resident who was admitted with multiple diagnoses, including hypertensive crisis, likely acute intracranial hemorrhage, left PCA occlusion, dementia with word-finding difficulties, and ambulatory dysfunction. Upon admission, the resident's blood pressure was recorded at 192/103, which exceeded the threshold for intervention as outlined in the facility's policy and the physician's order for as-needed antihypertensive medication. Despite this, documentation did not show that the ordered medication was administered following the elevated blood pressure reading. The resident's care plan indicated the need for antihypertensive medication and required staff to observe for side effects and promptly notify the physician if any were observed. However, there was a lack of communication and follow-through among staff regarding the resident's abnormal vital signs. The CNA who took the vital signs did not report the elevated blood pressure to the LPN, and the LPN was unaware of the abnormal reading. The resident was not entered into the electronic medical record system, which contributed to the lack of documentation and follow-up. The resident was later found unresponsive and pronounced deceased. Interviews with staff revealed confusion about reporting protocols and a lack of clarity regarding responsibilities for monitoring and responding to abnormal vital signs. The facility's failure to monitor and provide medications as ordered by the physician resulted in neglect of the resident's care needs, as evidenced by the lack of timely intervention for the hypertensive crisis.
Removal Plan
- Administrator notified the Medical Director of the Immediate Jeopardy.
- Director of Nursing and/or designee initiated education for all staff on Abuse/Neglect policies and procedures.
- All staff (including any agency assigned staff) that have not completed education will not be permitted to work until education is completed.
- Director of Nursing and/or designee initiated education to all nursing staff on procedure for follow up on abnormal vital signs.
- Director of Nursing and/or designee initiated education to all CNAs related to reporting abnormal vital signs.
- Director of Nursing and/or designee initiated an audit on all residents' Medication Administration Records (MARs) with anti-hypertensive and/or cardiovascular medications to ensure medications were given as ordered.
- 10 residents receiving cardiac medications will be audited weekly for 4 weeks and monthly for 2 months to ensure medications are given as ordered.
- Director of Nursing and/or designee initiated education with CNAs on facility policy and procedure for following checklist for taking resident vital signs.
- Director of Nursing and/or designee initiated education with all licensed nurses on what medications are available in Omnicell and how to pull medications from the Omnicell.
- Director of Nursing and/or designee initiated education for all licensed nurses on entering residents into PCC (PointClickCare) timely upon admission.