Failure to Notify Physician of Abnormal Blood Pressure Readings
Penalty
Summary
The facility failed to notify a resident's physician when the resident's blood pressure readings were outside of their baseline range. Specifically, the resident, who had a medical history including COPD, depression, lymphoma, and lung and bladder cancer, had blood pressure readings that were both below and above their baseline. On one occasion, the resident's blood pressure dropped to 89/62 mmHg, and on the following day, it rose to 172/94 mmHg. There was no documentation of a recheck of the blood pressure during the 12-hour interval between these readings, nor was there any record of communication with the physician regarding these abnormal values. During interviews and record reviews, the DON confirmed that there was no nurse-to-physician communication note or any documentation addressing the resident's condition related to these blood pressure readings. The facility's policy required physician notification when vital signs were out of range from the resident's baseline for two or more consecutive episodes, but this protocol was not followed in this instance.