Failure to Clarify Blood Pressure Medication Parameters and Notify Physician of Elevated Readings
Penalty
Summary
A deficiency occurred when a resident with hypertension and type 2 diabetes mellitus was administered the blood pressure medication Losartan without specific parameters in the physician's order to guide when the medication should be withheld. The medication order did not include instructions regarding minimum systolic blood pressure or heart rate thresholds, and the nursing staff did not clarify the order with the physician. Multiple licensed nurses and the Director of Nursing confirmed that the order lacked these parameters, and it was the facility's usual practice to include such parameters or verify them with the physician. The physician also stated that he expected staff to clarify orders and that parameters should have been in place to prevent adverse effects such as hypotension. Additionally, the same resident experienced two episodes of elevated blood pressure readings, with systolic values of 173 and 168, on the same day during different shifts. These readings were significantly higher than the resident's baseline and outside the normal range. Despite this, there was no documentation that the physician was notified of these abnormal values. Nursing staff and the Director of Nursing acknowledged that the physician should have been informed of these elevated readings, and the physician confirmed that he was not contacted and would have expected notification for such results. Facility policy required licensed nurses to assess, document, and communicate changes in condition, including abnormal vital signs, to the primary care provider. The failure to clarify medication parameters and to notify the physician of significant changes in blood pressure constituted a lack of adherence to professional standards of practice and facility policy, resulting in the identified deficiency.