Failure to Obtain Complete Vital Signs After Unsuccessful Machine Readings
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing services met professional standards of quality when complete vital signs were not obtained for a resident with significant cardiac history after multiple unsuccessful attempts. The resident had diagnoses of essential hypertension and atherosclerotic heart disease of native coronary artery without angina and was care planned for coronary artery disease with an intervention to monitor blood pressure and notify the physician of abnormal readings. The resident was also documented as DNR. The Weights and Vitals Summary showed the resident’s last recorded vital signs were taken several days before the incident, despite the care plan requirement to monitor blood pressure. On the day of the incident, a CNA attempted to obtain the resident’s blood pressure at approximately 3 p.m. using a vitals machine tower and was unable to get a reading after four attempts. The CNA reported that the machine displayed three horizontal lines on the first two attempts and “ERR” on the third and fourth attempts, and did not attempt to use a manual blood pressure monitor. The CNA did not report any broken vitals machine tower to maintenance, and the Maintenance Supervisor later stated that none of the eight vitals machine towers had been identified as broken prior to his quarterly checks. The facility’s Owner’s Manual for the touchscreen vital signs monitor indicated that certain error codes required the monitor not be used and that service be contacted, and the DON explained that three horizontal lines meant the machine was trying to obtain a reading and “ERR” meant the cuff was not properly attached and the machine was not pumping air. The CNA notified an LVN at approximately 5:30 p.m. that she was unable to obtain the resident’s blood pressure using the vitals machine. The LVN stated she intended to use a manual blood pressure monitor because the machine’s cuff sometimes did not work, but she did not notify anyone that the vitals machine was not working and did not complete the vital sign assessment before going to lunch. When the LVN returned from lunch around 7 p.m., she was informed the resident was unresponsive; the LVN found the resident pale, cold, and without signs of life. An alert note documented that at 7:15 p.m. the resident was found unresponsive in bed and that the DON, physician, and family were notified. The DON later stated that if a CNA was unable to obtain vital signs, the nurse should have checked the vital signs and the CNA should have attempted to use a manual blood pressure monitor, consistent with the facility’s policies on change in condition and obtaining vital signs, which require reporting changes to a licensed nurse and having the nurse assess and determine appropriate interventions, including vital signs when there is a change in condition.
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