Failure to Accurately Obtain and Document Orthostatic Blood Pressure Readings
Penalty
Summary
The facility failed to properly obtain and document accurate orthostatic blood pressure readings for a resident who was admitted with diagnoses including bipolar disorder, muscle weakness, and lack of coordination. The resident was cognitively intact and had no issues with upper or lower extremity movement. Physician and pharmacist orders required weekly monitoring for orthostatic hypotension by taking blood pressure readings in two different positions, 3-5 minutes apart, and to notify the physician if there was a significant drop in blood pressure. However, review of the Medication Administration Records over several weeks showed that the blood pressure readings recorded for both lying and sitting positions were exactly the same each time, with no variation. During an interview and record review, the Director of Staff Development noted that it was suspicious and questionable for the readings to be identical, as some variation would always be expected. The DSD was unable to determine if the issue was due to improper technique, documentation errors, or a problem with the charting system. The facility's policy defined orthostatic hypotension and outlined the correct procedure for measurement, which was not followed in this case. As a result, the documentation did not provide accurate information to determine if the resident had orthostatic hypotension.