Failure to Ensure Nursing Staff Competency in Following Physician Orders for BP Assessment
Penalty
Summary
The facility failed to ensure that nursing staff, specifically an LVN and RNs, demonstrated the necessary competencies and skills to follow physician orders for blood pressure assessment for a resident. The resident in question was admitted with diagnoses including toxic encephalopathy and depression, and was determined by a physician to lack capacity for decision-making, though the Minimum Data Set indicated cognitive intactness. The resident's care plan did not address the diagnosis of hypotension, despite a physician order to monitor for orthostatic hypotension once weekly. Review of the Medication Administration Record showed that the required monitoring for orthostatic hypotension was not documented on the specified date. During interviews, it was confirmed that the LVN did not follow the facility's job description, which requires accurate and timely documentation of resident assessments and care. The absence of documentation was interpreted by staff as evidence that the assessment was not performed. Further interviews with the DON and review of job descriptions for both LVNs and RNs revealed that the nursing staff did not fulfill their responsibilities for documentation and implementation of physician orders. The DON acknowledged that the RNs did not complete the required documentation or provide the ordered care, and stated that additional training was needed for the involved staff.
Plan Of Correction
F 726 Competent Nursing Staff Corrective Action: LVN 4 is no longer employed at facility. Other Residents Affected Identification: There are no other residents affected by this deficient practice. Measures and Systemic Change: DON/Designee initiated skills competency (on 05/02/25) regarding accurate blood pressure monitoring for all Licensed Nurses on 05/02/2025. DSD to ensure all new hires have a skills competency prior to starting. Monitor 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.