Failure to Assess and Notify Physician for Elevated Blood Pressure
Penalty
Summary
The facility failed to assess a resident during multiple episodes of elevated blood pressure and did not notify the physician in a timely manner, as required by the resident's care plan and physician orders. The resident, who had a history of hemiplegia, cerebral infarction, atherosclerotic heart disease, and hypertension, was cognitively impaired and required varying levels of assistance with daily activities. Physician orders and care plans directed staff to monitor blood pressure regularly and notify the physician of significant abnormalities or changes in condition. Despite these directives, the resident experienced several documented episodes of systolic blood pressure above 150 mmHg over a period of months, with no evidence that staff assessed the change in condition or notified the physician as required. On the day of transfer to an acute care hospital, the resident had multiple high blood pressure readings and reported a headache, but staff did not notify the physician until after the condition had escalated. Upon arrival at the hospital, the resident was diagnosed with hypertensive urgency. Interviews with nursing staff and the DON confirmed that staff did not follow the care plan or facility policy regarding monitoring and physician notification for elevated blood pressure. Facility policies and job descriptions required staff to observe for changes in resident status, notify the physician and family, and document accordingly, but these procedures were not followed in this case.