Failure to Notify Physician and Representative of Resident's Low Blood Pressure
Penalty
Summary
The facility failed to notify a resident's representative and physician of significant changes in the resident's condition, specifically repeated episodes of low blood pressure. The resident had multiple complex diagnoses, including pneumonia, COPD with acute exacerbation, respiratory failure, dehydration, and hypertension. On several occasions, the resident's blood pressure readings were notably low, with values in the 80s/40s-60s mmHg range. Despite these abnormal findings, there was no documentation in the nursing progress notes that the resident's representative or physician were notified of these changes on the dates the low blood pressures were recorded. Interviews with facility staff and the resident's representative confirmed that no notifications were made regarding the low blood pressure readings. The DON acknowledged that staff are expected to notify the physician and representative of such changes and document these actions, but this was not done. The LPN involved admitted to not notifying the representative or provider and did not recheck the blood pressure. Both the physician and APRN stated they were not informed of the low blood pressure episodes and emphasized the need for notification and follow-up. The facility's policy requires prompt notification and documentation when there is a significant change in a resident's condition, which was not followed in this case.