Failure to Document Blood Pressure Prior to Antihypertensive Administration
Penalty
Summary
A deficiency occurred when the facility failed to administer medication in accordance with physician orders and professional standards of practice for a resident with diagnoses including hypertension, hypotension, and epilepsy. The physician's order specified that Losartan Potassium should be administered only if the resident's systolic blood pressure (SBP) was greater than 100. However, review of the Medication Administration Record (MAR) showed that the medication was given from 5/8/25 to 5/15/25 without documentation that the resident's blood pressure was checked and confirmed to be above the required threshold prior to administration. Both the LVN who administered the medication and the DON confirmed that there was no documentation of blood pressure being checked as required by the order. The resident experienced a change in condition on 5/15/25, including a seizure, unresponsiveness, and a recorded blood pressure of 80/54, which led to transfer to the hospital. The hospital discharge summary listed syncope and collapse as the principal diagnosis. Facility policy required that vital signs be checked and verified prior to medication administration when necessary, but this was not documented in the resident's records during the relevant period.