Failure to Notify Physician and Administer Antihypertensive Medication for Elevated Blood Pressure
Penalty
Summary
The facility failed to provide necessary care and services for a resident with a diagnosis of high blood pressure, PTSD, and anxiety. On review of the resident's medical record, it was found that only one blood pressure reading was obtained, which was 142/86 mmHg—above the normal range. There was no documentation that the blood pressure was retaken or that the physician was notified of this abnormal result, despite facility policy and physician orders requiring such actions for elevated readings. Additionally, the resident had physician orders for Verapamil to be administered for hypertension, with specific instructions to hold the medication if the systolic blood pressure was greater than 110 mmHg. The medication was not administered as ordered, and there was no documentation that the physician was notified of the missed dose or the elevated blood pressure. Interviews with facility staff confirmed that these actions were not taken and not documented in the resident's record.