Failure to Develop Individualized Care Plan for Orthostatic Hypotension
Penalty
Summary
The facility failed to develop and implement an individualized care plan for a resident with orthostatic hypotension (OH), despite the resident's history of symptomatic OH that interfered with participation in physical therapy. The resident was admitted with multiple diagnoses, including OH, history of falls, pleural effusion, diabetes mellitus, postprocedural pneumothorax, and muscle wasting. Documentation showed that the resident required substantial assistance with activities of daily living and had intact cognitive skills. Orders were in place for physical and occupational therapy, and the resident experienced episodes of low blood pressure during therapy sessions, which were communicated to nursing staff. A physician ordered Midodrine to address the low blood pressure episodes. Despite these clinical findings and the administration of Midodrine, the facility did not create a care plan specific to the resident's diagnosis of OH or the use of Midodrine. Review of care plans revealed no individualized interventions addressing OH, such as timing therapy sessions after medication administration or monitoring orthostatic vital signs. Interviews with facility staff, including the MDS nurse and DON, confirmed that a care plan for OH was necessary and should have included specific interventions to ensure resident safety and support therapy participation. Facility policies required care plans to address all resident needs based on assessments and changes in condition, but this was not followed in this case.