Failure to Notify MD and Document When Antihypertensive Dose Was Held for Low Vitals
Penalty
Summary
The deficiency involves the facility’s failure to follow its policy and procedure for medication and treatment administration and physician notification for a resident with significant cardiac conditions. The resident had chronic CHF, hypertension, and atrial fibrillation, and a care plan dated 9/22/2025 directed staff to monitor vital signs as needed and notify the physician of significant abnormalities. An MDS dated 9/25/2025 documented that the resident had severely impaired cognitive skills for daily decision making and required substantial to total assistance with transfers, mobility, and all ADLs, indicating high dependence on staff for care and monitoring. On 10/18/2025 at 7:03 PM, the resident’s BP was recorded as 72/51 mmHg and HR as 57 bpm, which were documented in the Weights and Vitals Summary and later in a progress note at 9:52 PM. The resident had an active order, dated 9/19/2025, for bisoprolol fumarate 10 mg orally every 12 hours for hypertension, with instructions to hold the medication if systolic BP was less than 110 or HR less than 60. RN 1 acknowledged in a phone interview that the evening dose of bisoprolol on 10/18/2025 was not administered because the resident’s BP and HR were low. Despite the low BP and HR and the held dose of bisoprolol, RN 1 did not notify the physician that the medication was not given or that the resident’s vital signs were low, and did not recheck the BP and HR after obtaining the low readings. The progress notes did not document any physician notification or repeat vital signs, nor did they record the reason the bisoprolol was withheld. The facility’s P&P titled Medication and Treatment Administration Records, revised 1/2026, required that medications be administered as prescribed, that the attending physician be notified when an order cannot be administered as prescribed, and that an explanation be recorded in the nurses’ notes when a routine medication is withheld. The ADON confirmed that RN 1 did not follow these requirements, resulting in the cited deficiency.
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