Failure to Follow Physician Order for Daily Vital Sign Monitoring
Penalty
Summary
A deficiency occurred when the facility failed to follow a physician's order to monitor and document a resident's vital signs daily. The resident, who has a history of hypertension, COPD, and asthma, reported experiencing frequent migraines and sensations of elevated blood pressure. Although a nurse practitioner had recently ordered daily vital sign monitoring, the resident stated that staff were not checking his blood pressure daily, and the nurse confirmed that while she had monitored the vital signs, she did not document them in the electronic medical record. Instead, the nurse wrote the readings on a piece of paper, which was later discarded. A review of the resident's records revealed significant gaps in documentation, with only one blood pressure reading logged for June and none for April and May, despite an active order for daily monitoring. The resident's care plan included monitoring for hypertension and symptoms associated with high blood pressure, but the lack of consistent documentation and adherence to the physician's order resulted in a failure to provide appropriate care as directed. Facility policy requires all physician orders to be implemented and followed, but this was not done in this case.