Failure to Notify Physician of Significant Blood Pressure Drop
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident received care consistent with professional standards of practice by not notifying the physician after a significant change in blood pressure. The resident, who had diagnoses including unspecified psychosis, unspecified dementia, and essential hypertension, was admitted with orders to monitor for orthostatic hypotension and to notify the physician if there was a 20 mmHg drop in systolic blood pressure (SBP) or a 10 mmHg drop in diastolic blood pressure (DBP) between lying and sitting positions. On the specified date, the resident's SBP dropped by 20 mmHg from lying to sitting position, as documented in the Medication Administration Record (MAR). Despite this significant change, there was no documentation that the physician was notified as required by the physician's order and the facility's policy on changes in a resident's condition. The Director of Nursing confirmed that the nurse did not follow the physician's order to notify the physician of the blood pressure drop and acknowledged that the facility's policy mandates prompt notification of the physician for significant changes in a resident's condition.