Failure to Notify Nurse of Critically Low Blood Pressure Leads to Resident Death
Penalty
Summary
A deficiency occurred when a medication aide (MA) failed to notify a licensed vocational nurse (LVN) of a resident's significantly low blood pressure readings, which were far below the resident's baseline. The resident, an elderly female with a complex medical history including acute respiratory failure, hypertension, pneumonia, asthma, respiratory failure, and COPD, had a blood pressure reading of 86/54 and later 75/41. Despite holding the resident's blood pressure medication due to the low readings, the MA did not inform the LVN of these critical changes. The resident's care plan and physician orders required close monitoring of vital signs and immediate notification to the nurse practitioner (NP) or physician if there were significant changes, such as hypotension or symptoms like lethargy or confusion. The NP had specifically ordered that any change in blood pressure or symptoms should prompt sending the resident to the emergency room. However, the lack of communication from the MA to the LVN meant that the NP was not notified, and the resident did not receive timely medical intervention. As a result of this failure to follow professional standards of practice and the resident's care plan, the resident was eventually found unresponsive and was sent to the emergency room, where she was diagnosed with sepsis and hypotension. The resident died two days later in the hospital. Interviews with facility staff confirmed that the MA did not report the low blood pressure readings to the LVN, and the LVN stated she would have taken further action had she been informed.