Failure to Notify Physician of Repeated Hypotensive Episodes
Penalty
Summary
The facility failed to notify the physician of significant changes in condition for a resident who experienced eight episodes of hypotension related to the use of Losartan Potassium-HCTZ. Despite the resident having a history of subdural hemorrhage, syncope, end stage renal disease requiring dialysis, atherosclerotic heart disease, and atrial fibrillation, there was no documentation that the physician or the resident's responsible party was notified of these repeated low blood pressure readings. The medication order specifically instructed staff to hold the medication if the systolic blood pressure was less than 110 mmHg, which occurred on multiple occasions. The resident reported experiencing syncope both during dialysis treatments and while in bed at the facility, and attributed these symptoms to the new blood pressure medication. The resident communicated these symptoms to the LVN, who confirmed that the medication was held on several dates due to low blood pressure readings. However, the LVN did not notify the physician or the responsible party, nor did she document a change of condition in the medical record regarding these hypotensive episodes. The DON stated that any deviation from a resident's baseline blood pressure, especially when accompanied by symptoms such as syncope, should be reported to the physician and documented as a change of condition. The facility's policy required that sudden or serious changes in a resident's condition be communicated to the physician prior to the end of the assigned shift. Despite these requirements, there was no evidence that the physician was notified or that appropriate documentation was made for the resident's repeated episodes of hypotension and related symptoms.