Failure to Follow Physician Orders and Use Approved Equipment for Blood Pressure Monitoring
Penalty
Summary
The facility failed to provide necessary care and services by not monitoring a resident's blood pressure according to physician orders and resident preferences. Specifically, staff used a wrist blood pressure machine, which the resident reported as inaccurate, and repeatedly obtained low systolic readings. The resident expressed concerns about the accuracy of the device and stated that nurses often had to retake his blood pressure multiple times to get an accurate reading. Additionally, the resident reported that staff were obtaining blood pressure readings from his left arm, which contained a hemodialysis access site, despite a physician order prohibiting blood pressure measurements from that site. Medical record review confirmed the resident had diagnoses of end stage renal disease on hemodialysis, hypertension, and a history of diabetes. Physician orders included instructions to hold antihypertensive medication if systolic blood pressure was below a certain threshold and a specific order not to obtain blood pressure readings from the left arm with the hemodialysis access. During interviews, a nurse admitted to using a wrist blood pressure machine and to taking readings from whichever arm the resident offered, while the DON confirmed that only facility-approved machines should be used and that staff should follow physician orders regarding blood pressure monitoring.