Failure to Address and Document Low Blood Pressure in Resident
Penalty
Summary
Facility staff failed to address a resident's change in condition when the resident repeatedly presented with low blood pressure readings following dialysis treatments. The resident and a family member reported that after returning from dialysis, the resident often felt unwell and requested blood pressure checks, which consistently showed readings below the normal range. Despite these findings, there was no documentation of interventions or physician notification in the resident's medical record, as confirmed by the Director of Staff Development. The facility's grievance log also indicated the resident was dissatisfied with how blood pressure checks were conducted by a CNA. Review of the resident's orders showed no current medication for low blood pressure, and interviews with staff confirmed that the physician should have been notified for systolic blood pressure readings below 100 mm Hg. The facility's policy required nurses to notify the attending physician and document any significant changes in a resident's condition, but this was not done in this case. The lack of intervention and documentation for the resident's persistently low blood pressure constituted a failure to meet professional standards of quality.