Failure to Notify Physician and Assess Resident with Abnormal Vitals and Change in Condition
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards, the resident's care plan, and the resident's preferences for one resident reviewed for quality of care. Specifically, the facility did not document assessments or notify the physician when the resident's vital signs were abnormal over several days, despite clear parameters in the physician's orders for when to hold antihypertensive medications and when to notify the physician. The resident's blood pressure and heart rate were repeatedly below the specified thresholds, and antihypertensive medications were held accordingly, but there was no documentation of physician notification or further assessment. Additionally, staff and the resident's family expressed concerns about the resident's lethargy and fatigue throughout the week, but these concerns were not adequately addressed or escalated. The resident involved was an elderly female with a history of multiple fractures, hypertension, atrial fibrillation, chronic pain, and repeated falls. Upon admission, she required assistance with mobility and activities of daily living and had occasional urinary incontinence. During her stay, her blood pressure and heart rate were frequently low, and she exhibited increasing lethargy and fatigue, as noted by therapy staff, family, and in some nursing documentation. Despite these symptoms and abnormal vital signs, there was no evidence that the physician was notified or that further interventions were implemented until the resident's condition became critical. On the day her condition significantly worsened, the resident's family measured a critically low blood pressure and alerted nursing staff, who then assessed the resident and found her to be lethargic and minimally responsive. Only at this point was the physician notified, and the resident was transferred to the hospital, where she was diagnosed with sepsis from a urinary tract infection. Interviews with staff revealed inconsistent understanding and application of protocols for notifying the physician of abnormal vital signs and changes in condition, and the facility did not have a policy on blood pressure assessments. The deficiency was identified as Immediate Jeopardy due to the failure to ensure timely treatment and care in accordance with orders and standards of practice.
Removal Plan
- Inform the Medical Director of the Immediate Jeopardy.
- In-service licensed staff on notifying physician of abnormal vital signs when accompanied by symptoms and standard disease related clinical interventions by the licensed nurse are not successful.
- Train staff on notifying the physician of abnormal vital signs when accompanied by symptoms and standard disease related clinical interventions by the licensed nurse are not successful, assessing a resident for change of condition, and notifying physician of change in conditions.
- Review all patients for documented low blood pressure. If a patient is noted to have blood pressures outside of the specified order parameters, notify the MD or NP. If neither are available, or in an emergent situation, contact emergency services (911).
- In-service ADON, Administrator, Medical Records, and Wound Care Nurse on notifying physician of change of condition and assessing the patient for change in condition and identifying a major decline or improvement in the resident's status.
- Initiate staff (LVN, RN, CNA) in-servicing on notifying of changes in condition and quality of care. Any staff who have not received in-servicing will not be permitted to work until in-servicing has been completed. In-servicing will be on-going for PRN, new staff, staff on leave, agency (if applicable).
- If a CNA obtains abnormal vital signs they will notify their charge nurse immediately. Charge nurse will then re-assess resident and re-take vital signs. The physician is to be notified of abnormal vital signs when accompanied by symptoms and standard disease related clinical interventions by the licensed nurse are not successful.
- Notify the physician of abnormal vital signs when accompanied by symptoms and standard disease related clinical interventions by the licensed nurse are not successful, based upon direction of the medical director.
- Define abnormal vital signs as: Systolic BP less than 90, Diastolic less than 50, Systolic greater than 180, Diastolic greater than 100, Heart rate less than 50, Heart rate greater than 130.
- ADON/DON/designee will review the exception report for low blood pressures with systolic blood pressures less than 90 and diastolic less than 50. Review will occur daily for 2 weeks, then 5 times weekly for 6 weeks, then 3 times weekly for 4 weeks.