Failure to Monitor and Document Blood Pressure After Change in Condition
Penalty
Summary
The facility failed to ensure proper blood pressure monitoring following a change in condition for a resident with a history of left-sided hemiplegia, hemiparesis, psychophysiologic insomnia, epileptic syndrome, and cognitive and emotional deficits after cerebrovascular disease. On the day of the incident, the resident was noted to have altered mental status and slurred speech, and a CNA reported these changes to an RN. The RN found the resident's blood pressure to be significantly low (66/40), and after interventions such as laying the resident down and providing fluids, the blood pressure improved slightly. The physician and the resident's son were notified, and the physician instructed continued monitoring, with the RN relaying the situation to the oncoming nurse at shift change. Despite these instructions and the facility's policy requiring documentation of changes in condition and ongoing monitoring, there was a lack of documented blood pressure readings and vital signs after the initial incident. The only documented blood pressure readings were at the time of the incident and one subsequent reading, with no times recorded for the latter. Progress notes indicated that monitoring was to continue, but there were no further documented vital signs or blood pressure checks in the medical record, and the electronic charting tab showed no recent entries. Interviews with staff confirmed that vital signs should have been monitored and documented until the resident was stable, but this was not done.