Failure to Notify Physician of Resident’s Elevated Blood Pressures
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician of significantly elevated blood pressures as required by facility policy. The facility’s policy on Change in a Resident’s Condition or Status, revised February 2021, states that the nurse will promptly notify the attending or on-call physician when there is a significant change in the resident’s physical condition, defined as a major decline or improvement that will not normally resolve without intervention. The resident was admitted with diagnoses including Alzheimer’s disease, essential hypertension, and hypothyroidism, and had an active order for Benazepril 5 mg daily for hypertension with instructions to hold the medication if systolic blood pressure (SBP) was less than 110. The admission MDS showed the resident was unable to complete the BIMS interview and had an active diagnosis of hypertension. Blood pressure records showed multiple elevated readings, including 172/102 and 172/101 on one day and 171/119 on the following day. Review of the nurse’s notes revealed no documentation that the physician or PACE program was notified of these elevated blood pressures. The care plan indicated the resident was a PACE participant and directed staff to contact PACE for any medical needs. During interviews, the UM stated all medication orders came from PACE, and the DON acknowledged that 171/119 was an elevated blood pressure and that a call should have been made to the on-call PACE medical director, with family also to be notified of the change in condition. The patient liaison and weekend supervisor both reported not being informed of the elevated blood pressures, and CNA staff reported notifying an RN of the elevated readings but was unsure what occurred afterward. The RN stated she did not recall the patient but indicated that if there was no progress note, the notification would not have been documented anywhere else.
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