Failure to Reassess and Notify Physician for Low Blood Pressure and Wound Infection
Penalty
Summary
The facility failed to provide necessary care and services for a resident with multiple complex medical conditions, including end stage renal disease, diabetes with a foot ulcer, dependence on dialysis, peripheral vascular disease, and acute osteomyelitis. On the morning of the incident, the resident was found to have a low blood pressure reading of 90/42 mmHg. The assigned nurse administered midodrine as ordered but did not reassess the resident's vital signs after administration or prior to sending the resident to dialysis. The nurse also did not notify the physician of the low blood pressure, despite being aware that dialysis can further lower blood pressure and that the resident was at risk for clinical instability. The RN Supervisor was informed of the low blood pressure and administration of midodrine but also did not reassess the resident or notify the physician. The resident was subsequently transferred to the hospital from the dialysis center due to hypotension. Additionally, the facility failed to notify the physician when a foul-smelling odor was observed from the resident's right Achilles wound during wound care treatment the previous day. The wound had worsened, with increased swelling, maceration, and slough tissue, and the presence of a foul odor, which may indicate infection. The treatment nurse did not document a change in condition or notify the physician to obtain updated treatment orders. The wound care consultant, who assessed the resident the following day, noted signs of infection and significant pain but was not informed by staff of the foul odor observed earlier. Interviews with facility staff, including the DON, confirmed that the nurses were responsible for ensuring residents were stable before being sent to dialysis and for notifying the physician of significant changes in condition, such as low blood pressure or signs of wound infection. The facility's policies and job descriptions also required prompt notification and documentation of changes in condition. The failures to reassess the resident, notify the physician, and document changes in condition had the potential to delay necessary care and treatment.