Incomplete Documentation of Vital Signs for Antihypertensive Medication Parameters
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records for a resident receiving antihypertensive medication with specific vital sign parameters. The resident, an older adult with diagnoses including heart failure, heart disease, and hypertension, had an admission MDS showing a BIMS score of 9, indicating moderate cognitive impairment, and required substantial staff assistance for most ADLs. The resident’s care plan identified hypertension with associated risks and included interventions to administer antihypertensive medications as ordered, check and document blood pressure per MD order, and hold medication and notify the MD per facility protocol if blood pressure was below ordered parameters. Physician orders and the Nursing MAR for the month showed an order for carvedilol 3.125 mg by mouth every 12 hours at 8 AM and 8 PM, with instructions to hold the medication for systolic blood pressure less than 105, diastolic blood pressure less than 60, and heart rate less than 60, and to monitor vital signs daily. However, review of the MAR from 3/01/26 through 3/19/26 revealed no documentation of blood pressure or heart rate for the 8 PM carvedilol dose. The DON acknowledged that there was no place on the MAR to document a second set of vital signs for the 8 PM dose and that, although some vital signs appeared in nurses’ notes, they were not timed, so it was not possible to determine their relationship to the medication administration. A medication aide who typically worked the 2 PM to 10 PM shift stated that when administering medications with blood pressure and pulse parameters, she documented those vital signs on the MAR and that, if a medication was ordered more than once daily, there should be a place to document vital signs with each administration. She confirmed that there was no place on this resident’s MAR to document blood pressure or pulse for the 8 PM carvedilol dose, even though she reported checking them before administration. She further stated that if blood pressure and pulse were not documented, it was as if they were not checked, and there would be no way to tell if the medication was given within the physician’s parameters. The facility’s medication administration policy required medications to be administered as prescribed and for vital signs to be checked and verified, if necessary, prior to administration, underscoring the incomplete documentation for this resident’s evening carvedilol doses.
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