Failure to Monitor and Report Abnormal Blood Pressure Readings
Penalty
Summary
Facility staff failed to appropriately monitor and respond to abnormal blood pressure readings for a resident with chronic obstructive pulmonary disease, chronic kidney disease, and hypertension. Medical record review showed that on two separate occasions, the resident had significantly abnormal blood pressure readings—one low (91/40) and one high (203/99)—without documentation of a recheck or notification to a physician or provider. Interviews with staff revealed inconsistent practices regarding the rechecking of abnormal blood pressures and provider notification, with one LPN stating she only rechecks if time allows and does not notify providers, while an RN described a protocol of rechecking and notifying based on symptoms. The DON confirmed that staff are expected to recheck abnormal blood pressures within two hours and notify providers, regardless of symptoms. Further review of facility policy indicated that any blood pressure reading above 140/90 is considered hypertension and below 100/60 is hypotension, and that abnormal readings should be reported to a physician and documented at different times of the day. The physician interviewed confirmed that staff should recheck and notify providers if abnormal readings persist. The deficiency was identified during a complaint investigation and affected one resident out of 15 reviewed for blood pressure monitoring, with a facility census of 94 residents.