Failure to Notify Physician of Elevated Blood Pressure Readings
Penalty
Summary
Nursing staff failed to notify the medical provider of a resident's consistently elevated blood pressure readings over a period of several weeks. The facility's policy required nurses to inform the physician or on-call physician in situations where there was a need to alter medical treatment or when a significant change in the resident's physical, emotional, or mental condition occurred. Despite multiple blood pressure measurements that were significantly above normal parameters, there was no documentation in the nursing progress notes that the physician had been notified. The resident involved had a history of dementia, hypertension, cognitive communication deficit, anxiety, and chronic pain, and was under an active order for blood pressure and pulse monitoring twice daily, with instructions to recheck if out of parameters. However, the care plan and physician orders did not specify a recommended blood pressure range or parameter. The Director of Nursing confirmed that staff did not notify the medical provider of blood pressure values outside the resident's baseline and acknowledged that additional blood pressure measurements should have been taken to ensure the resident's well-being.