Failure to Monitor and Document Blood Pressure as Ordered
Penalty
Summary
A deficiency occurred when the facility failed to monitor and document a resident's blood pressure as ordered by the primary physician. The resident, who was admitted with diagnoses including hypertensive heart disease without heart failure and depression, had a physician's order to be monitored for orthostatic hypotension once a week on Saturdays. On the specified date, there was no documentation in the Medication Administration Record (MAR) that the blood pressure monitoring was completed. An interview with a licensed vocational nurse confirmed that the assigned nurse did not assess or document the resident's blood pressure, and that if documentation was missing, the assessment was not performed. The resident's care plan did not address hypertensive heart disease or the required blood pressure monitoring, despite the resident having an active diagnosis of hypertension. The facility's policy required nurses to assess and document vital signs, including blood pressure, as part of baseline information for acute condition changes. The lack of documentation and assessment was confirmed through record review and staff interview, indicating the ordered monitoring was not carried out as required.
Plan Of Correction
F6841 Quality of Care Corrective Action: Resident 1 was discharged on 04/03/2025. LVN 4 is no longer employed at the facility. Other Residents Affected Identification: On 5/2/2025, IP Nurse reviewed residents with Blood Pressure monitoring orders. All Blood Pressure Monitoring reflecting on MAR are all being done and documented as ordered by MD. There are no other residents affected by the deficient practice. Measures and Systemic Change: MRD/Designee will initiate a weekly audit on 05/02/25 of all residents with Blood Pressure Monitoring to ensure it is done and documented on the MAR per MD's order. Monitoring Performance: The DON/Designee will present the results to the QA Committee for monthly review for the next 3 months and quarterly thereafter or until substantial compliance is achieved.