Failure to Monitor Orthostatic Blood Pressure in Residents on Psychotropic Medications
Penalty
Summary
The facility failed to ensure appropriate monitoring for two residents who were receiving psychotropic medications. For one resident with vascular dementia and hypotension due to drugs, there was an active physician order for Seroquel, an antipsychotic, with instructions to monitor for side effects including orthostatic hypotension. However, there was no physician order for orthostatic blood pressure readings, and a review of the electronic medical record showed that no orthostatic blood pressures had been documented. The Director of Nursing confirmed that the expectation was to monitor and document orthostatic blood pressures. Another resident with diagnoses including type 2 diabetes, malnutrition, schizoaffective disorder, major depressive disorder, and anxiety was receiving Abilify, an antipsychotic, with a physician order to monitor for side effects such as orthostatic hypotension. The resident was cognitively intact according to the most recent assessment. Despite the order, the medical record did not reflect evidence of routine orthostatic blood pressure monitoring, and the DON stated that such documentation would be found in the vital signs section or progress notes, but none was present.