Failure to Document Repeat Blood Pressure Prior to Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident, specifically regarding the administration of Metoprolol Succinate, a blood pressure medication. The physician's order required the medication to be held if the resident's systolic blood pressure (SBP) was less than 100 mmHg, diastolic blood pressure (DBP) was less than 60 mmHg, or heart rate (HR) was less than 60. On the date in question, the resident's DBP was recorded as 57 mmHg, which was below the threshold for medication administration. The medication administration record indicated that the medication was given, but the blood pressure and pulse values were documented as 'NA,' with no definition provided for this notation. Further review of the electronic medical record revealed two blood pressure readings for that day: one at 127/57 mmHg and another at 150/69 mmHg. There was no documentation of a repeat blood pressure check or a progress note regarding the administration of Metoprolol Succinate or reassessment of the resident's blood pressure. During interviews, the nurse responsible for administering the medication could not recall the specific event but stated she would typically re-check blood pressure if initial values were outside the administration range. She acknowledged that if she had re-checked the blood pressure, she likely did not document the new values, which would result in a medication administration error. The Director of Nursing confirmed that the facility's policy required accurate and timely documentation of all assessments and care provided, including repeat vital signs when indicated by medication orders. The lack of documentation for the repeat blood pressure value was identified as a failure to maintain a complete and accurate medical record, as required by professional standards and facility policy.