Failure to Follow Physician Order for Blood Pressure Monitoring
Penalty
Summary
The facility failed to follow a physician's order for daily blood pressure monitoring for one resident who was severely cognitively impaired and had multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, non-Alzheimer dementia, malnutrition, anxiety, depression, and psychotic disorder. The physician's order required daily blood pressure checks from 01/30/25 through 02/24/25, but the resident's clinical record lacked documentation of blood pressure readings on several specified dates within this period. Interviews with nursing staff confirmed that such monitoring should be documented in the Electronic Medication Administration Record, and the Corporate Clinical Support Nurse stated there was no specific policy for following physician orders, relying instead on standards of practice.