F0842

D

Incomplete Documentation of Held Antihypertensive Medication

Gallup, New Mexico Survey Completed on 01-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain complete and accurate medical records related to medication administration for one resident prescribed carvedilol for hypertension and other cardiac conditions. The physician’s order dated 11/20/25 directed that carvedilol be held only if the resident’s systolic blood pressure was less than 110 mmHg or heart rate was less than 60 beats per minute. Review of the Medication Administration Record (MAR) for 01/01/26 showed the morning dose of carvedilol was documented as not administered with a direction to “see progress note,” while the recorded vital signs that morning were a systolic blood pressure of 118 mmHg and heart rate of 70 beats per minute, which were within the ordered parameters for administration. No corresponding progress note was found for that date explaining why the medication was withheld.

Further review of the MAR from 01/01/26 to 01/21/26 showed that the evening dose of carvedilol on 01/01/26 was documented as administered, with the same vital signs recorded for that evening as in the morning (systolic blood pressure 118 mmHg and heart rate 70 beats per minute). On 01/16/26, the evening dose of carvedilol was again documented on the MAR as not administered with a notation to “see nurses note,” yet the resident’s vital signs that day showed a systolic blood pressure of 156 mmHg and heart rate of 60 beats per minute, which were within the parameters for giving the medication. No nursing note was entered on 01/16/26 or 01/17/26 to explain the reason for withholding the dose. In an interview, the DON stated that when a nurse documents a medication as held with a direction to see a note, it is expected that a corresponding note be entered, and confirmed that the resident’s medical record regarding medication administration was not accurate.