Failure to Complete and Document Ordered Orthostatic Blood Pressures
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document physician-ordered orthostatic blood pressures for a resident being evaluated for dizziness and lightheadedness. The resident had diagnoses of anxiety and hypotension and an admission MDS BIMS score of 14, indicating intact cognition. The care plan documented use of an antihypotensive medication for hypotension, with directions to monitor and document side effects and effectiveness, and to verify blood pressure and pulse prior to administering the medication. Following a progress note documenting low blood pressure and the resident’s report that their blood pressure had always been low, the provider ordered orthostatic blood pressures twice daily for three days, with lying, sitting, and standing measurements and instructions to send the results via EMR message. The EMR contained the order starting on 02/28/26. Despite this order, the EMAR showed incomplete and missing orthostatic blood pressure documentation. On 02/28/26, only a single blood pressure reading was recorded without the required lying, sitting, and standing values, and there was no documentation for the evening orthostatic set. On 03/01/26, the morning orthostatic entry was marked as not applicable, and the evening entry required reference to a nurse’s note because the system would not allow entry of the readings in the designated fields; the nurse’s note documented all three positions. On 03/02/26, again only a single blood pressure reading was recorded, with no orthostatic breakdown, and no evening orthostatic documentation. Staff interviews revealed that CNAs typically obtained vital signs and nurses later entered them into the computer, that one CMA only checked vitals before certain heart medications and not for this resident, and that one nurse preferred to perform orthostatic measurements herself due to concerns about CNAs’ technique. The administrative nurse stated that orthostatic results should be entered into the EMR and messaged to the provider, but staff were unable to locate these messages. No policy regarding orthostatic blood pressures was provided.
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