Failure to Ensure Staff Competency in Orthostatic Hypotension Monitoring
Penalty
Summary
The facility failed to ensure that licensed nurses and nurse aides possessed the necessary competencies to properly obtain and evaluate orthostatic hypotension in residents. The Director of Nursing (DON) and Assistant Administrator confirmed that annual competency evaluations specific to orthostatic hypotension monitoring were not conducted or documented for the staff, including LVNs and LPTs. The facility's policy defined orthostatic hypotension and required reporting significant changes to a physician, but there was no evidence that staff were trained or assessed on this procedure. Interviews with staff revealed a lack of knowledge regarding the correct parameters for orthostatic hypotension and inconsistent practices in monitoring and documentation. Medical record and facility document reviews showed multiple instances where residents had significant drops in blood pressure readings between sitting and standing positions, consistent with orthostatic hypotension, but these were not properly identified, documented, or reported. For example, one resident had a diastolic blood pressure drop of 19 mmHg, and another had a drop of 12 mmHg, yet there was no evidence of appropriate follow-up or physician notification. Additionally, medication administration records and change of condition logs indicated that blood pressure readings were sometimes recorded incorrectly or not compared as required by policy. Interviews with nursing staff further demonstrated gaps in knowledge and competency. Some staff were unable to state the correct criteria for orthostatic hypotension or the appropriate actions to take when significant changes were observed. Others relied on CNAs to obtain vital signs but did not verify or interpret the results according to policy. The DON acknowledged that staff had not been specifically trained or evaluated on orthostatic hypotension monitoring, and this lack of competency assessment was confirmed by the DSD and other administrative staff.