Failure to Monitor Hypotension, Delay in Reporting Lab Results, and Delay in Stat Urine Collection
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident as required by physician orders, resident preferences, and established policies and procedures. Specifically, the facility did not adequately monitor the resident's blood pressure for hypotension, despite multiple readings below the defined threshold of 100/60 mmHg. Blood pressure measurements were only taken twice per day over two days, and staff interviews confirmed that more frequent monitoring was warranted but not performed. Additionally, the facility did not promptly report abnormal laboratory results to the resident's physician. A CBC test revealed an elevated white blood cell count, which was received by the facility at 1256 hours but not communicated to the physician until over three hours later. Both nursing staff interviewed acknowledged that the results, indicating a possible infection, should have been reported immediately upon receipt. The facility also failed to collect a stat urine sample in a timely manner after a physician's order was placed. The order for a UA with C&S stat was entered at 1747 hours, but the urine sample was not collected until 2218 hours the same day. Staff interviews confirmed that the sample should have been collected immediately following the order. These failures were verified through observation, interviews, and medical record review.