Failure to Notify Physician of Abnormal Blood Pressure Readings
Penalty
Summary
Facility staff failed to notify the physicians of two residents after documenting multiple abnormal blood pressure (BP) readings below the threshold specified in the residents' physician orders. Both residents had diagnoses including hypertension and were prescribed antihypertensive medications with explicit instructions to hold the medication if BP readings fell below 100/60 mmHg. Despite repeated low BP readings and withheld medication administrations, there was no documentation that the physicians were informed of these abnormal findings or the medication holds. For one resident with moderate cognitive impairment and a history of hypertension, staff recorded several instances of low BP readings and withheld doses of Hydralazine as ordered. The resident's family expressed concern about the consistently low BP and requested a physician appointment, but there was no evidence that the physician was notified or that the concern was escalated. The physician later confirmed that he was not informed of the abnormal BP readings and would have expected notification to reassess and adjust treatment as necessary. A second resident, cognitively intact with heart failure and hypertension, also experienced multiple days of low BP readings resulting in held doses of antihypertensive medications. Again, there was no documentation of physician notification regarding these abnormal readings or medication holds. Interviews with staff, including the DON, LPN, and CMT, confirmed the expectation to notify the physician and document such notifications, but this was not done in these cases. The physician reiterated the expectation for notification to allow for timely intervention.