Continuing Healthcare At Forest Hill

medication orders included parameters for holding or administering the medication based on the resident's blood pressure.Review of a progress note dated 10/26/25 at 9:15 A.M. revealed the nurse was called to the resident's room by the Certified Nurse Aide. (CNA).

The resident was sitting in her wheelchair with her head back, flaccid, not responding to voice commands or touch.

The nurse sent the CNA to get another nurse.

The residents' vital signs were taken.

The resident had a change of mental status compared to baseline.

The nurse practitioner (NP) was notified and 911 was called. Resident #58 was transferred to the hospital emergency room (ER) to be evaluated.

Review of the vital sign record for Resident #58 dated 10/26/25 at 9:15 A.M., revealed the resident had a recorded pulse of 47 beats per minute and blood pressure of 110/60 documented. (Normal blood pressure is generally considered 120/80 millimeters of mercury (mm/Hg)).Review of Emergency Medical Transport documentation for Resident #58 dated 10/26/25 at 9:50 A.M., revealed the resident's heart rate was 73 and her blood pressure was 75/50 mm/Hg (hypotensive).Review of emergency room documentation for Resident #58 dated 10/26/25 revealed the resident arrived at the emergency room at 10:09 A.M., with a complaint of an unresponsive episode. At that time, her blood pressure was 83/50 and her heart rate was 69. At 11:56 A.M., the resident's blood pressure was 82/52 and her heart rate was 50. At 1:50 P.M., her blood pressure was 101/59, after administration of 1000 milliliters of normal saline intravenously at 12:16 P.M.Further review of the emergency room Record revealed the resident was discharged back to the facility with recommendation to have the primary care provider review the resident's blood pressure medications, which may have needed adjustment.On 11/17/25 at 12:13 P.M., an interview with Licensed Practical Nurse (LPN) #106 revealed if a resident had a medication which required vital signs to be taken prior to administration, the nurse would have to enter the vital measurement into the documentation prior to administration.

However, there were no facility protocols for blood pressure or pulse monitoring for any residents receiving blood pressure medications, only those who had parameters listed.Review of standard of care for applying the nursing process to administering cardiovascular medications (Nursing Pharmacology [internet]; 2nd edition. https://www.ncbi.nlm.nih.gov/books/NBK594995/), revealed before administering cardiovascular medications, it was vital for the nurse to determine if the specific medication was safe for the client at that time.

Because antihypertensives alter a client's blood pressure or heart rate, the nurse must assess blood pressure and heart rate prior to administering medications.Review of a facility policy titled Medication Administration and Documentation, updated 06/26/24, revealed it was the policy of the facility that every resident receives medication by a licensed nurse as prescribed by a licensed physician or other healthcare provider legally permitted to prescribe medications, safely, properly and in a timely manner.

This same policy revealed it was expected the individual administering medications was familiar with the expected action, dosage and side effects of medications administered. If there was clinical data, such as vital signs, required for medication administration, this must be obtained prior to administration.This deficiency represents non-compliance investigated under Complaint Number 1353963.

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