Failure to Monitor and Record Daily Vital Signs as Ordered
Penalty
Summary
The facility failed to ensure that a resident received daily vital sign monitoring as ordered by a physician and as part of a QAPI initiative to prevent rehospitalization. The resident, an elderly female with severe dementia, hypertension, and generalized anxiety disorder, had physician orders for daily vital signs, including blood pressure, pulse, temperature, respiration, and oxygen saturation, starting from late March. Despite these orders, there were 58 days within a 68-day period where no vital signs were recorded for the resident. Record reviews confirmed that the resident's care plan included monitoring for abnormal blood pressure due to cardiac disease, and medication orders for antihypertensive drugs were in place. However, documentation showed that vital signs were not consistently obtained or recorded, and direct observation revealed that staff did not take blood pressure or pulse prior to administering blood pressure medication. Interviews with nursing staff and medication aides indicated confusion regarding responsibility for obtaining vital signs, with some staff believing the order was no longer valid or that it was the nurse's responsibility rather than the medication aide's. Further interviews with nursing leadership revealed that the QAPI order for daily vital signs was not set up correctly in the system, which prevented proper tracking and auditing. The responsible nurse who initiated the order was no longer employed at the facility, and there was no specific policy for vital signs beyond following physician orders. The lack of daily vital sign monitoring as ordered was acknowledged by both nursing and administrative staff, who recognized the potential for unacknowledged changes in condition and possible hospitalization.