Failure to Report Repeated Hypotension to Physician
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of repeated episodes of hypotension for one resident with known cardiovascular issues and an order for antihypertensive medication. The resident had an MDS BIMS score of 15/15, indicating intact cognition, and a care plan identifying altered cardiovascular status related to persistent hypotension with a goal to remain free from complications of cardiac problems. The physician’s order for Metoprolol Tartrate 100 mg (two tablets at bedtime) included parameters to hold the medication if systolic blood pressure (SBP) was less than 100 or heart rate less than 60. The facility’s own Blood Pressure Measuring policy defined hypotension as BP less than 100/60 mmHg and required that hypotension be reported to the physician, and its Guidelines for Notifying Physicians of Clinical Problems directed staff to report SBP less than 90 mmHg. Despite these parameters and policies, the resident’s Weights and Vitals Summary from 12/1/25 to 12/9/25 showed ten separate instances of SBP less than 100 mmHg that were not reported to the physician. On 12/9/25, documentation of a change of condition noted the resident with hypotension and altered mental status after routine night medications around 2030, with a blood pressure of 75/44 and pulse 76 at 11:30 p.m., and repeat readings mostly in the range of 73–85 systolic and 37–46 diastolic. The resident was subsequently sent to a general acute care hospital that night for low blood pressure and confusion, where a physical exam documented a blood pressure of 87/39 mmHg. During interviews, an LVN stated that SBP less than 90 mmHg should be rechecked and reported to the physician, and the ADON acknowledged that specific low readings (90/56, 86/56, and 86/56) should have been reported and that there was no documentation of physician notification for two hypotensive episodes on 12/8/25. The DON stated that reportable blood pressure was defined in physician orders and that nurses should follow ordered parameters, while also recognizing the importance of reporting hypotension so physicians are aware of resident blood pressure assessments. These observations, interviews, and record reviews show that the facility did not follow its policies or physician parameters to report hypotension to the physician for this resident.
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