Failure to Notify Provider of Abnormal Blood Pressure Readings
Penalty
Summary
The facility failed to notify the provider of abnormal vital signs for one resident, as required by policy. The resident, an elderly female, had multiple episodes of significantly elevated blood pressure readings, including 209/92, 236/104, and 213/102, with no evidence of timely reassessment or provider notification documented in the medical record. The provider only became aware of the elevated blood pressure by reviewing the electronic health record, not through direct communication from nursing staff. Interviews with nursing staff and the nurse practitioner confirmed that the expectation was for providers to be notified of out-of-range blood pressures and for such communication to be documented. The facility's policy required informing the provider of significant changes in a resident's condition, including clinical complications or the need to alter treatment. Despite this, there was no documentation that the provider was notified of the resident's elevated blood pressures, nor was there evidence of prompt reassessment following the abnormal readings.