Failure to Monitor Orthostatic Blood Pressures Due to Transcription Error
Penalty
Summary
A deficiency occurred when the facility failed to ensure that orthostatic blood pressures were monitored daily as ordered by the physician for a resident with a history of orthostatic hypotension and repeated falls. The resident, who was cognitively intact and required some assistance with transfers and toileting, had a care plan that included monitoring for signs and symptoms of orthostatic hypotension. Despite a physician's order for daily orthostatic blood pressures, the order was not transcribed onto the Medication Administration Record (MAR) or Treatment Administration Record (TAR), and as a result, the blood pressures were not taken or documented. Interviews with nursing staff and review of the clinical record revealed that the order was incorrectly entered into the electronic health record (EHR) and was not carried over to the MAR or TAR. This transcription error was not identified during routine order audits, and nursing staff were unaware of the order or its requirements. The facility's policy required accurate transcription and verification of orders, but this process was not followed, leading to the omission of the required monitoring for the resident.