F0684

D

Failure to Verify NPO Medication Orders and Monitor PRN Antihypertensive Therapy

Livermore, California Survey Completed on 02-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide care that met professional standards for a resident with dementia and hypertensive heart disease who was scheduled for PEG placement and placed on NPO status. An SBAR note documented that the resident was NPO in preparation for the procedure and that BP medications were withheld because of the NPO order. When the resident’s BP was checked at 1:00 p.m., it was critically elevated at 207/97 mmHg, and the resident was subsequently transferred to the hospital later that afternoon for critical high blood pressure. The DON stated that the expectation was for charge nurses to verify with the physician whether BP medications should be given when a resident is NPO for a procedure, but this verification did not occur.

The facility’s own Surgery-Related (Pre- and Postoperative) Management policy indicated that the physician should evaluate residents scheduled for surgery with attention to cognition, function, and control of active co-morbidities such as hypertension, and that modifiable risk factors like blood pressure should be stabilized prior to transfer for surgery. The policy also required staff and the physician to review the relevance of preoperative medications and adjust them as needed. In this case, the resident’s antihypertensive regimen was altered by withholding BP medications due to NPO status without documented physician verification, despite the resident’s known hypertensive heart disease and poor cognition (BIMS score of 00).

A second component of the deficiency concerns the facility’s failure to obtain and document follow-up BP readings after administration of PRN hydralazine as ordered. The physician’s order directed hydralazine 25 mg PO every 6 hours PRN for SBP >160. Record review, confirmed by the DON, showed multiple instances in May, July, and August where the resident’s SBP readings were significantly elevated (ranging from 183 to 198 mmHg), PRN hydralazine was administered, but no follow-up BP checks were documented. The DSD and DON both stated that licensed nurses were required to recheck BP 30 minutes after PRN hydralazine to monitor effectiveness, document the results, and notify the physician if BP remained elevated. The facility’s Acute Condition Changes policy required nurses to collect and report pertinent baseline information, including vital signs, and to contact the physician based on urgency, but this monitoring and communication process was not followed for the resident’s repeated episodes of severe hypertension.