Failure to Monitor Orthostatic Blood Pressure in Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to ensure appropriate monitoring for side effects of antipsychotic medication, specifically orthostatic hypotension, for one resident who was prescribed Olanzapine and other psychotropic medications. The resident was cognitively intact, had a high risk for falls, and had a physician's order for monthly orthostatic blood pressure checks due to the use of psychotropic medications. However, a review of the resident's electronic medical record, including medication and treatment administration records, vital signs, and progress notes, showed no evidence that these orthostatic blood pressure readings had been obtained or documented for the past two months. Interviews with facility staff, including medication aides, LPNs, and the nurse manager, confirmed that the order for monthly orthostatic blood pressure monitoring was present but had not been carried out or recorded. Staff indicated that such orders should appear in the medication administration record, but none were found for any residents, including the one in question. The facility's policy required monitoring for side effects and adverse consequences of antipsychotic medications, including cardiovascular effects like orthostatic hypotension, but this was not followed in this case.