The violation at Coast Care Convalescent Center occurred daily from December 13 through December 22, when staff administered losartan to a resident with hypertensive heart disease and moderate cognitive impairment. The doctor had ordered nurses to hold the medication if the resident's heart rate dropped below 60 beats per minute.
They never checked to find out.
The resident, who requires maximum assistance with basic functions like toileting and supervision with eating, was readmitted to the facility with diagnoses including hypertensive heart disease — a condition where prolonged high blood pressure damages the heart over time. The December 18 assessment showed the patient had moderate cognitive impairment.
On December 13, the physician issued a clear order: hold losartan for heart rate less than 60 beats per minute daily. The facility's own care plan, revised December 22, specified that staff should obtain vital signs and administer medication as ordered to maintain the resident's quality of life.
The medication administration record told a different story. It showed the resident received losartan at 9 AM every single day from December 13 through December 22. But there were no heart rate readings documented before any of those doses.
During the December 23 inspection, the Infection Preventionist Nurse explained what should have happened: "When the physician ordered to hold losartan for heart rate of less than 60 BPM, the licensed nurse should check the resident's heart rate prior to the medication administration and document the readings."
The Director of Nursing confirmed the failure during a review of the resident's vital signs summary. There were no heart rate readings documented at 9 AM on December 13, 15, 16, 17, 18, 19, 20, or 22.
"The licensed nurse did not carry out the physician order to check Resident 1's heart rate prior to the administration of losartan," the Director of Nursing stated during the inspection.
The medication in question, losartan, treats high blood pressure but can affect heart rate. For patients with existing heart conditions, monitoring pulse before administration is crucial to prevent dangerous drops in heart rate that could compromise circulation and organ function.
Coast Care's own policies required compliance with the physician's orders. The facility's undated policy on physician orders states that staff should provide care and services in accordance with medical directives. Another policy mandates that licensed nurses implement and carry out physician orders within two hours of receiving them.
The facility's vital signs policy, revised in January 2024, specifically requires taking vital signs "as ordered by the physician and before giving medication when there were conditional parameters of administration." The heart rate check fell squarely within this requirement.
The Infection Preventionist Nurse emphasized the importance of following through on medical orders: "It was important for the licensed nurse who received the physician order to carry out and transcribe to electronic MAR. Carrying out the physician order meant to do the action as ordered."
But for ten straight days, that didn't happen.
The resident's condition made the oversight particularly concerning. With hypertensive heart disease, the heart muscle has already been compromised by prolonged high blood pressure. Adding a blood pressure medication without monitoring heart rate could potentially cause dangerous cardiovascular effects, especially if the heart rate dropped below the physician's specified threshold.
The violation affected the resident's safety and represented a fundamental breakdown in medication administration protocols. Despite having clear physician orders, documented policies, and a vulnerable patient with known heart disease, nursing staff repeatedly failed to perform the basic vital sign check that could have prevented potential harm.
The inspection found that the licensed nurse responsible for medication administration simply ignored the conditional parameter that would have required holding the medication if the resident's heart rate was too low. Without checking the heart rate, there was no way to know whether the resident was receiving medication that could have been contraindicated.
Federal inspectors classified the violation as having minimal harm or potential for actual harm, but noted it had the potential to compromise the resident's health and safety. The failure continued for ten days until inspectors discovered it during their December 23 visit.
The case illustrates how seemingly simple medication administration errors can compound into serious safety risks, particularly for residents with complex medical conditions who depend entirely on nursing staff for proper monitoring and care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Coast Care Convalescent Center from 2025-12-23 including all violations, facility responses, and corrective action plans.
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