Failure to Monitor and Document Vital Signs for Medications With Hold Parameters
Penalty
Summary
The deficiency involves the facility’s failure to monitor and document required vital signs for a resident receiving medications with physician-ordered hold parameters, resulting in a drug regimen that was not shown to be free from unnecessary drugs. The resident had paroxysmal atrial fibrillation, congestive heart failure, and hypertension, and was prescribed digoxin 125 mcg with instructions to hold the dose if the pulse was below 60. Over multiple months, the MAR showed daily administration of digoxin except on days the resident was out of the facility, but the hold parameter was not transcribed onto the MAR and there was no pulse documentation on the MAR. Review of the electronic health record revealed numerous dates across several months with no recorded pulse, despite ongoing administration of digoxin. The resident was also prescribed losartan 100 mg daily with a physician order to hold the medication if systolic blood pressure was less than 110. The MAR documented daily administration of losartan beginning in February, but again, the hold parameter was not transcribed on the MAR and there was no blood pressure documentation on the MAR. The electronic record contained only two blood pressure entries for that month, and the facility could not produce additional blood pressure documentation. Multiple nurses reported that parameters should have been entered into supplemental documentation to flag the need for pulse and blood pressure checks, acknowledged that this was not done, and could not explain why monitoring and documentation were missed. The nurse responsible for entering and confirming orders stated that orders with parameters were not always entered correctly due to lack of staff knowledge and that sometimes the same nurse both entered and confirmed orders. The physician stated she expected her hold-parameter orders to be followed and identified potential adverse effects, while the DON and Administrator both reported they were unaware that the parameter monitoring and documentation were not being carried out.
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