Failure to Notify Physician of Repeated Elevated Blood Pressures
Penalty
Summary
Resident rights related to timely physician and family notification were not honored when abnormal clinical findings were not reported. One resident with multiple diagnoses including schizoaffective disorder, depression, and anxiety had four documented episodes of elevated blood pressure over a 90-day period, with readings of 171/104, 164/98, 171/99, and 173/104. Record review showed no documentation that the physician was notified of any of these elevated blood pressure readings. During an interview on 3/6/26 at 9:20 AM, the DON stated that nurses should have notified the physician immediately of the elevated blood pressures and was unable to provide any documentation that such notification occurred. This failure to notify the physician of abnormal vital signs was identified for 1 of 16 residents reviewed for physician notification and was determined by surveyors to have placed the resident at risk for harm.
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