Failure to Notify Physician and Representative of Missed Antihypertensives and Elevated BP
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician and resident representative of a change in condition and missed medications for a resident with multiple comorbidities. The resident was admitted from the hospital with diagnoses including type 2 diabetes mellitus with hyperglycemia, chronic kidney disease, hypertension, and hypokalemia, and had severe cognitive impairment and dependence on staff for activities of daily living. Hospital discharge orders included multiple antihypertensive medications (lisinopril, amlodipine, atenolol, hydralazine, and hydrochlorothiazide), which were continued in the facility’s physician orders. On the evening of admission, the resident did not receive the evening doses of atenolol and hydralazine, and the following morning did not receive hydrochlorothiazide, lisinopril, or the morning doses of amlodipine, hydralazine, and atenolol. There was no documentation that the physician or family were notified that these medications were not administered. Vital sign records showed elevated blood pressures, including readings in the 160s/80s and a later reading of 193/99, with no documentation of a morning blood pressure on the day after admission. There was no documentation that the physician was notified of the elevated blood pressure of 193/99 after the resident had not received ordered antihypertensive medications. A late-entry nursing note documented that the resident’s blood pressure was elevated, that medications had just arrived from the pharmacy, and that a family member at the bedside was concerned; however, facility records showed that the ordered antihypertensive medications were already available on hand. The DON confirmed that medications were not administered as ordered, that available medications should have been used, and that the nurse should have clarified pre-transfer medications and notified the physician and family of the missed doses and elevated blood pressure. Facility policies required notification of the physician and resident representative for changes in condition and physician notification when medications are withheld.
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