Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
Facility staff failed to promptly notify a resident's physician and responsible party of significant changes in the resident's condition, specifically regarding multiple episodes of low blood pressure. The resident, an older male with a history of hypertension, hypotension, heart failure, and other complex medical conditions, experienced several consecutive low blood pressure readings over multiple days. Despite these abnormal vital signs and the withholding of prescribed blood pressure medication due to the low readings, staff did not inform the physician or nurse practitioner as required by facility policy. Documentation showed that the resident's blood pressure was repeatedly below normal, with readings such as 85/59, 70/53, 73/55, and as low as 62/50 over a span of days. These findings were recorded by medication aides and nurses, who also withheld the resident's blood pressure medication in response to the low readings. However, there was no evidence that the physician or nurse practitioner was notified of these changes until the resident was being evaluated for an unrelated hospital transfer. Interviews with the physician and nurse practitioner confirmed that they were not made aware of the resident's ongoing low blood pressure, and both stated that notification should have occurred, especially given the need to withhold medication and the potential for underlying causes. The DON acknowledged that staff did not notify the physician, attributing the oversight to the resident's history of low blood pressure, but facility policy required notification for acute changes in condition. The deficiency was identified through interviews, record reviews, and policy examination.