Failure to Notify Physician and Document Care for Hypotensive Resident Prior to Dialysis
Penalty
Summary
A deficiency occurred when a resident with multiple complex diagnoses, including end stage renal disease, hypertensive heart and kidney disease, and dependence on dialysis, did not receive care in accordance with professional standards. The resident's care plan included interventions to maintain hemodynamic stability, such as administering medications as ordered, monitoring vital signs, and notifying the physician of any abnormalities. On the day in question, the resident exhibited low blood pressure prior to dialysis, which was noted by the LPN on duty. The LPN administered Midodrine, an anti-hypotensive medication, based on a standing order but did not notify the RN in charge or the physician about the resident's hypotensive state before sending the resident to dialysis. Interview and record review revealed that the LPN could not recall the exact blood pressure readings but confirmed they were below the resident's baseline. The LPN also stated that the resident's husband expressed concern about the low blood pressure, but the LPN reassured him and proceeded with the dialysis schedule. Documentation in the medication administration record did not show that Midodrine was administered on the date in question, and there was no record of communication with the RN or physician regarding the resident's condition prior to dialysis. The facility's communication report to the dialysis center noted the low blood pressure but did not indicate that anti-hypotensive medication had been given. Further review with the Director of Nursing confirmed that nurses are expected to assess vital signs, review medication administration, and communicate any significant changes in condition to the physician. However, the decision to notify the physician was left to nursing judgment. The lack of documentation and failure to notify the appropriate clinical staff or physician of the resident's low blood pressure prior to dialysis constituted a failure to meet accepted standards of clinical practice and professional standards of quality.