Failure to Notify Physician of Held Blood Pressure Medications and Abnormal Vital Signs
Penalty
Summary
The facility failed to notify a resident's physician after blood pressure medications were held for three consecutive days due to low blood pressure. According to the facility's policies, the physician should be notified of significant changes in a resident's condition, including abnormal vital signs and when medications are held. Review of the clinical record for a resident with a history of hypertension, hypokalemia, and anemia showed that blood pressure readings were significantly lower than the resident's baseline, and heart rates were elevated over several days. Despite these findings, there was no documentation that the physician was notified about the low blood pressure, elevated heart rate, or the decision to withhold blood pressure medications. Nursing notes indicated that the resident experienced low blood pressure readings and elevated heart rates on multiple occasions, with the resident also exhibiting poor appetite and weakness. The medications Irbesartan, Metoprolol, and Nifedipine were not administered for three consecutive days due to these low readings. Staff interviews revealed that nurses recognized the abnormal vital signs and the deviation from the resident's baseline, but did not notify the physician or supervisor as required by facility policy. One nurse stated she rechecked the blood pressure and found it acceptable, but there was no evidence that the elevated heart rate was rechecked or that the physician was informed. Further interviews with the Director of Nursing confirmed that there was no written evidence of physician notification regarding the resident's low blood pressure, elevated heart rate, or the held medications. The DON acknowledged that the standard of practice is to notify the physician in such cases, and that sustained low blood pressure is a reason to contact the physician. The lack of documentation and failure to notify the physician constituted a deficiency in following the facility's policies and procedures for changes in resident condition and medication administration.