Failure to Follow Physician Order for Medication Administration
Penalty
Summary
A licensed nurse failed to follow a physician's order for a resident with hypertensive heart disease and generalized muscle weakness by not checking and documenting the resident's heart rate prior to administering losartan, a medication for high blood pressure. The physician's order specifically required that losartan be held if the resident's heart rate was less than 60 beats per minute, and that the heart rate be checked daily before administration. Review of the Medication Administration Record (MAR) and Vital Summary showed that from 12/13/2025 to 12/22/2025, the resident received ten doses of losartan without any documentation of heart rate readings prior to administration on multiple days. Interviews with the Infection Preventionist Nurse (IPN) and Director of Nursing (DON) confirmed that the nurse did not carry out the physician's order as required. Facility policies reviewed indicated that care and services should be provided in accordance with physician orders, and that vital signs must be taken as ordered, especially when there are conditional parameters for medication administration. The failure to check and document the heart rate prior to administering losartan constituted a violation of professional standards of quality and facility policy.