Failure to Follow Physician's Order for Bed Position and Notify Provider
Penalty
Summary
Staff failed to follow a physician's order for a resident with a history of orthostatic hypotension, which required the head of the bed to be elevated at all times, with some decline allowed at bedtime. Despite a visible sign above the resident's bed instructing staff to keep the head of the bed elevated, multiple observations over several days found the resident lying completely flat. Nursing staff reported that the resident would yell when the bed was elevated, leading them to routinely lower the bed, but there was no documentation that the physician or APRN was notified of the resident's inability to tolerate the upright position as ordered. The care plan did not include interventions related to the resident's hypotensive episodes or the need to remain upright in bed. Review of the clinical record showed no evidence of physician notification regarding the resident's intolerance to the ordered bed position. Interviews with clinical leadership confirmed they were unaware that staff were not maintaining the head of the bed elevation and had not been informed of the resident's reactions. Facility policies required notification of changes in condition and person-centered care planning, but these were not followed in this case.