Optalis Health & Rehabilitation Of Whitehall

Review of an admission Record revealed R10 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: congestive heart failure.Review of R10's Order Summary dated 10/27/25 revealed: Digoxin Oral Tablet 125 MCG (Digoxin) Give 1 tablet by mouth at bedtime for heart failure Hold for HR < 60 (heart rate less than 60).

Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 25 MG (Metoprolol Succinate) Give 0.5 tablet by mouth at bedtime for beta blocker (12.5 mg) Hold for HR < (less than) 60 or SBP < 90.Review of R10's Pulse Summary revealed the only assessments were completed on 12/8/25 and 12/24/25.Review of R10's December Medication Administration Record (MAR) revealed every dose of digoxin was administered from 12/1/25 through 12/22/25 and 12/24/25-12/25/25.Review of R10's Blood Pressure Summary revealed a blood pressure assessment was not completed on 12/2/25, 12/9/25, 12/10/25, 12/14/25, 12/15/25, 12/21/25, 12/23/25, or 12/25/25.Further review of the Blood Pressure Summary revealed:R10's blood pressure of 120/80 was documented in the MAR for 12/8/25, 12/9/25, and 12/10/25. R10's blood pressure of 138/64 was documented in the MAR for 12/13/25 and 12/14/25. R10's blood pressure of 135/67 was documented in the MAR for 12/20 and 12/21. R10's blood pressure of 124/74 was documented in the MAR for 12/22/25 and 12/23/25.

Review of R10's Electronic Medical Record revealed no documentation for the rationale for administering the medication without first obtaining a heart rate or blood pressure.Resident #11 (R11) Review of an admission Record revealed R11 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: congestive heart failure.Review of R11's Order Summary dated 11/26/25 revealed, Daily weights, report to provider if > (greater than) 3# (pound) gain in 1 day or 5# in 1 week every day shift for CHF (congestive heart failure).Review of R11's Weight Summary revealed a weight was not obtained on 12/8/25, 12/15/25, 12/16/25, 12/17/25, 12/20/25, or 12/25/25.From 12/9/25-12/10/25 R11 had a 3 pound 2 ounce weight increase.

There was no documentation that the provider was notified.From 12/19/25-12/21/25 R11 had a 9 pound weight increase.

There was no documentation that the provider was notified.

During an interview on 12/26/2025 at 3:01 PM, the DON confirmed that R8, R9, and R10's ordered parameters were not followed and that R11's weights were not constituently documented or acted upon.

The DON reported that the expectation was for licensed nurses to follow the provider orders and act upon them accordingly.

The DON reported that all licensed nurses would receive medication administration re-education.

Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, (Nurses) are also responsible for documenting any preassessment data required with certain medications such as a blood pressure measurement for antihypertensive medications or laboratory values, as in the case of warfarin, before giving the medication. [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME].

Fundamentals of Nursing - E-Book (pp. 643-644).

Elsevier Health Sciences.

Kindle Edition.Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, The seven rights of medication administration include the right medication, right dose, right patient, right route, right time, right documentation, and right indication.Responsibilities of medication administration include knowing medication therapeutics, assessing a patient before administration, calculating doses, administering medications using the seven rights, monitoring and evaluating medication effects, and assessing a patient's ability to self-administer medications. [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME].

Fundamentals of Nursing - E-Book (p. 705).

Elsevier Health Sciences.

Kindle Edition.

Facility ID: