Failure to Accurately Monitor and Document Orthostatic Blood Pressure
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident who was being monitored for unnecessary medications, specifically regarding the monitoring of orthostatic blood pressure (BP) as ordered by the physician. The physician's orders required daily monitoring of orthostatic BP in both lying and sitting positions. The resident's care plan addressed altered cardiovascular status and risk for hypertension and hypotension, with interventions including administration of antihypertensive medications and monitoring for side effects such as orthostatic hypotension. Medical record review showed that, on multiple occasions, the BP readings documented for both lying and sitting positions were identical, which is inconsistent with proper orthostatic BP measurement. During interviews, an LVN acknowledged that the matching BP readings were an error and could not provide evidence that accurate orthostatic BP readings were taken on several days. The DON also confirmed that BP readings for lying and sitting positions should not be the same each time. This failure to accurately monitor and document orthostatic BP as ordered constituted a deficiency in care.