Failure to Notify Physician and Intervene for Critically Low Blood Pressure
Penalty
Summary
The facility failed to provide timely interventions and notify the resident's physician after a resident presented with significantly low blood pressure, lethargy, and drowsiness. The resident, who had a history of hypertension, heart failure, anemia, and a recent thoracic spine fracture, was dependent on staff for transfers and required assistance with bed mobility. On the night in question, the resident's blood pressure readings were as low as 63/36 mmHg and 61/50 mmHg, and he was described as very drowsy, sleeping through assessments, but responsive when given scheduled pain medication. Despite these abnormal findings, there was no immediate notification to the physician as required by the care plan, which specified that the provider should be updated if the systolic blood pressure was less than 90 or diastolic less than 60. Interviews with staff and the physician confirmed that blood pressures below 90/50 mmHg should prompt physician notification. The LPN on duty attempted to verify the blood pressure readings with different cuffs, suspecting an error, but did not notify the physician or supervisory nursing staff as expected. The resident was later assessed by the ADON, who also noted abnormal presentation and low blood pressure, and confirmed that the expectation was for the nurse to reassess with a manual cuff and notify appropriate personnel. The DON and Administrator echoed these expectations. The failure to follow established protocols for assessment and notification led to a delay in appropriate medical intervention for the resident.