Failure to Follow Physician Orders and Notify Physician of Elevated Blood Pressure
Penalty
Summary
The facility failed to follow physician orders for a resident who was admitted with multiple diagnoses, including fractures, malignant neoplasm of the glottis, and chronic venous hypertension with ulcer. Physician orders required orthostatic blood pressure (BP) measurements (lying, sitting, and standing) every shift, as well as a two-person assist for transfers. Review of the resident's medical record revealed that BP readings were inconsistently documented, with several instances where only one or two positions were recorded and some shifts with no BP readings at all. Additionally, there were multiple elevated BP readings documented, but there was no evidence that the physician was notified of these findings, nor was there documentation in the progress notes regarding any such notification. Interviews with the DON, ADON, and RN Coordinator confirmed that physician orders for orthostatic BP monitoring were not followed and that the physician was not notified of high BP readings as required. The physician also confirmed he was not informed of the elevated BP results and expected to be notified for systolic BP readings of 160 or above and diastolic readings of 90 or above. The failure to follow physician orders and notify the physician of significant clinical findings was confirmed through record review and staff interviews.