Failure to Obtain Orthostatic Blood Pressure as Ordered
Penalty
Summary
The facility failed to provide necessary care and services as ordered for a resident diagnosed with orthostatic hypotension. The physician's order required that the resident's orthostatic blood pressure and pulse rate be checked daily in lying, sitting, and standing positions for three days. However, a review of the Medication Administration Record (MAR) for the specified period showed that only single blood pressure and pulse readings were documented each day, without specifying the required positions. Further review of the medical record confirmed that the orthostatic blood pressure measurements in all three positions were not obtained as ordered. During interviews, both the LVN and the DON acknowledged that the required assessments were not completed and verified the absence of documentation for the ordered positions. The failure to follow the physician's order was confirmed through both record review and staff interviews.