Failure to Notify Provider of Abnormal Vitals and Withheld Medications
Penalty
Summary
Facility staff failed to notify providers of abnormal vital signs and the withholding of medication for three residents with significant medical conditions. For two residents with hypertensive heart disease, staff documented multiple instances of low blood pressure readings that were outside the parameters set by physician orders. Despite these abnormal readings and the decision to hold prescribed antihypertensive medications, there was no documentation that the provider was notified of the low blood pressure or the medication being withheld. Additionally, a resident with type 2 diabetes mellitus experienced several episodes of low blood sugar, as documented in the medical record. The facility's diabetic management policy and physician orders required staff to notify the provider when blood glucose levels fell below a certain threshold. However, there was no documentation that the provider was informed of these low blood sugar episodes, nor was there evidence that the required notifications were made according to policy. During an interview, the Director of Nursing confirmed that staff did not contact the provider regarding the low blood pressure readings, the withholding of blood pressure medications, or the low blood sugar levels, as required by physician orders and facility policy. The medical records lacked documentation of provider notification or any new orders resulting from these clinical findings.