Failure to Notify Provider of Abnormal Vital Signs
Penalty
Summary
Facility staff failed to notify the physician of abnormal vital signs for a resident with a diagnosis of essential hypertension. According to physician orders, staff were required to hold amlodipine and call the physician if the resident's systolic blood pressure (SBP) was less than 100, diastolic blood pressure (DBP) was less than 50, or pulse was less than 50. Additionally, staff were to administer the medication and call the physician if SBP was greater than 180, DBP was greater than 100, or pulse was greater than 100. Despite these clear parameters, staff documented multiple instances where the resident's SBP exceeded 180 and pulse was below 50, yet still administered amlodipine and did not notify the physician as required. Review of the Medication Administration Record (MAR) for April and May 2025 showed repeated occurrences of elevated blood pressure and low pulse readings, with no corresponding documentation of physician notification. Progress notes for March and April 2025 also lacked evidence of provider notification regarding these abnormal findings. The Director of Nursing confirmed that staff did not follow the order to notify the physician when the resident's blood pressure was elevated or pulse was low.