Failure to Notify Provider of Abnormal Vital Signs as Ordered
Penalty
Summary
Facility staff failed to notify the provider of abnormal vital signs for a resident with a diagnosis of essential hypertension. Physician orders specified that isosorbide should be held and the medical doctor notified if the resident's systolic blood pressure was less than 100 or greater than 150, or if the pulse was less than 50. Despite this, staff documented several instances where the resident's blood pressure exceeded 150 and the pulse dropped below 50, but there was no evidence that the provider was notified as required by the order. Review of the medication administration record showed that the resident continued to receive isosorbide daily during periods when vital signs were outside the specified parameters. The Director of Nursing confirmed that staff did not contact the physician or provider to report the elevated blood pressure and low heart rate, contrary to the physician's instructions. The expectation was for staff to notify the provider as directed in the order, but this did not occur.