Failure to Document Blood Pressure Readings When Holding Antihypertensive Medication
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records for a resident with essential primary hypertension. The resident, an older female with severe cognitive impairment (BIMS score of 7), had a care plan problem for hypertension with an intervention to administer antihypertensive medications as ordered. The physician’s order for amlodipine 10 mg daily included parameters to hold the medication for blood pressure less than 100/60. Review of the resident’s electronic MAR for March 2026 showed that on four specific dates, the nurse signed out the amlodipine as held due to low blood pressure, but no corresponding blood pressure readings were documented on the eMAR for those dates. During interview, LVN A stated she always checked the resident’s blood pressure before administering any blood pressure medication and confirmed she was able to sign the eMAR as held without entering the blood pressure reading. LVN A expressed confidence that the resident’s blood pressure had been below the ordered parameters on the four days in question and acknowledged the importance of accurate and complete documentation for medication adjustment and monitoring trends. The DON stated that blood pressure should always be measured before administering blood pressure medications and documented in the eMAR whether or not the medication was given, emphasizing the need for accurate history when reviewing records. Facility policy on Medication Administration required staff to sign the MAR after administration and to record vital signs on the MAR for medications requiring vital signs, which was not followed in this case.
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