Failure to Notify Physician of Elevated Blood Pressure
Penalty
Summary
The facility failed to notify a physician of a significant change in a resident's condition, specifically an elevated blood pressure reading. Medical record review showed that a resident with a history of chronic obstructive pulmonary disease, atrial fibrillation, bipolar disorder, and acute respiratory failure had a documented blood pressure of 167/124. Despite care plan interventions requiring monitoring and reporting of cardiovascular symptoms, there was no documentation of physician notification or follow-up blood pressure readings in the medical record, Medication Administration Record, or progress notes for the relevant dates. Interviews with the Director of Nursing confirmed that staff did not notify the physician about the elevated blood pressure, as required by facility policy. The policy mandates that the nurse supervisor or charge nurse must notify the resident's medical practitioner of changes in condition and document these actions in the medical record. The deficiency was identified during a complaint investigation and affected one resident out of three reviewed for change in condition.