Failure to Timely Notify Physician and Intervene for Hypertensive Crisis After Fall
Penalty
Summary
The facility failed to ensure that a resident received timely treatment and care in accordance with professional standards following an acute change in condition. After a fall in which the resident struck her head and sustained a laceration with hematoma, the resident's blood pressure was found to be significantly elevated, with multiple readings above 180/90 mmHg over a period of more than four hours. Despite these persistently high blood pressure readings, the physician was not notified in a timely manner, and no interventions were implemented to address the hypertensive crisis until several hours after the initial event. The resident had a history of hypertension, diabetes mellitus, and Alzheimer's disease, and was assessed as severely cognitively impaired and dependent on staff for all activities of daily living. Following the fall, neurological assessments and vital signs were documented at regular intervals, consistently showing elevated blood pressure. The facility's policy required prompt notification of the physician and implementation of interventions for significant changes in a resident's condition, such as persistently high blood pressure. However, the physician was not contacted until over four hours after the initial high blood pressure readings were documented, at which point a new order for antihypertensive medication was obtained, but the medication was not administered. Staff interviews confirmed that the standard of care would have been to notify the physician promptly if high blood pressure persisted, and that medication to lower blood pressure was available in the facility's emergency supply. The delay in physician notification and intervention resulted in the resident being transferred to the hospital later that day, where her blood pressure remained critically high. The deficiency centers on the facility's failure to follow its own policy and professional standards for timely physician notification and intervention in response to an acute change in the resident's condition.