Failure to Notify Physician of Resident's Critically Low Blood Pressure on Admission
Penalty
Summary
Facility staff failed to notify a resident's physician of a significantly low blood pressure (BP) reading upon admission. The resident, who had a history of atrial fibrillation and hypertension, was admitted with an initial BP of 64/40 mm/Hg. Despite this abnormal finding, there was no documentation or evidence that the physician was informed of the low BP, as confirmed by interviews with nursing staff and review of progress notes. The facility's policy required that hypotension, defined as BP less than 100/60 mm/Hg, be reported to the physician. On the evening of admission, the resident was found on the floor after slipping off the bed while attempting to use a urinal. At the time of the fall, the resident's BP remained low at 65/41 mm/Hg. Subsequent BP readings taken every 15 minutes showed gradual improvement, but the initial hypotensive episode was not communicated to the physician. Interviews with staff indicated awareness that such low BP readings should be reported, but the responsible nurse did not do so, citing being overwhelmed by multiple admissions. The Director of Nursing confirmed that there was no documented communication with the physician regarding the resident's low BP and acknowledged that staff should have monitored and reported the abnormal vital sign. The lack of physician notification was not documented in the resident's records, and the facility's policy on BP measurement and reporting was not followed in this instance.