Failure to Follow Antihypertensive Parameters and Accurately Document Hot Water Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing services met professional standards of practice for a resident receiving antihypertensive medications. Review of the resident’s MAR showed orders for Amlodipine 10 mg at bedtime and Metoprolol Succinate ER 50 mg daily for HTN, with instructions to hold both medications if the systolic blood pressure (SBP) was less than 110, and to hold Metoprolol if the heart rate was less than 60. On one morning, RN #28 administered Metoprolol despite the resident’s SBP being 101, which was below the ordered hold parameter. Review of the resident’s blood pressure readings showed multiple SBP values below 110 on several dates, including 103/57, 101/58, 102/57, 94/51, and 98/56. The medical record did not contain documentation that the physician was notified when the resident’s SBP was less than 110 or that the medication was held as ordered. A second deficiency was identified related to maintenance documentation of hot water temperatures. Review of the facility’s hot water logs showed that on multiple dates, a single temperature (ranging from 119°F to 121°F) was recorded with a line and downward arrow drawn through each box for every resident room, instead of documenting the actual temperature for each room. During interview, the Maintenance Director acknowledged that the hot water logs were not completed accurately or completely, confirming that the recorded temperatures did not reflect individual room measurements as required.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.