Failure to Notify Physician of Elevated Blood Pressures
Penalty
Summary
The facility failed to notify the physician of multiple instances of elevated blood pressure readings for a resident with a history of malignant neoplasms and essential hypertension. The resident was prescribed several antihypertensive medications and had a recent hospital admission for a stroke. Blood pressure readings documented over a one-month period showed several significantly elevated values, including readings as high as 222/138 mmHg. Despite these abnormal findings, there was no documentation in the clinical record that the physician had been notified of these elevated blood pressures. Interviews with nursing staff revealed inconsistency and lack of clarity regarding when to notify the physician about abnormal blood pressure readings. One LPN stated there was no standard protocol for physician notification, while another indicated she would notify the physician for blood pressures over 140, although there was no specific order for this. The DON confirmed there was no standing protocol for physician notification of abnormal vital signs unless directly ordered by the physician, but acknowledged that the physician should have been notified for blood pressures outside the resident's baseline. The facility's policy required prompt physician notification for changes requiring intervention or alteration of treatment, but this was not followed in the resident's case.