Failure to Clarify and Complete Orthostatic BP Monitoring Order
Penalty
No penalty information released
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Summary
A deficiency occurred when a physician's order for weekly orthostatic blood pressure (BP) monitoring while lying, sitting, and standing was not properly clarified or followed for one resident. The resident's medical record showed that the standing BP checks were not completed as ordered. During an interview and concurrent record review, the ADON confirmed that the resident was unable to stand without assistance from two staff members, making the standing BP check inappropriate for the resident's functional level. The physician's order was not clarified to reflect the resident's actual abilities, resulting in the order not being carried out as written.