Failure to Notify Physician of Resident's Low Blood Pressure Readings
Penalty
Summary
The facility failed to notify a resident's physician when the resident experienced multiple episodes of low blood pressure, as required by facility policy. The resident had a physician's order for Benazepril HCL to be held if systolic blood pressure (SBP) was less than 110 mmHg. Medical records showed several instances where the resident's SBP was below this threshold, including readings as low as 100/60 mmHg and, during a physical therapy session, as low as 83/57 mmHg while sitting. Despite these low readings, there was no documentation indicating that the physician was notified of the change in the resident's condition. Interviews with facility staff, including the physical therapist and the Director of Nursing (DON), confirmed awareness of the low blood pressure readings and acknowledged that the physician should have been informed. The DON also verified that facility policy required physician notification when blood pressure medication was held for three consecutive days, but there was no evidence this occurred. The deficiency was identified through interviews, medical record review, and review of facility policies and procedures.