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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.23 NURSING SERVICES, was out of compliance.

A-0395 A registered nurse must supervise and evaluate the nursing care for each patient. Based on interviews and record review, the facility failed to ensure nursing staff notified a provider when a patient had a sustained elevated blood pressure according to standards of practice in 1 of 1 medical records reviewed in which a patient had a change in condition (Patient #2).

Based on interviews and record review, the facility failed to ensure nursing staff notified the provider when a patient had a sustained elevated blood pressure according to standards of practice in 1 of 1 medical records reviewed in which a patient had a change in condition (Patient #2).

Findings include:

Facility policy:

The Adult Patient Standards of Care policy read, all patients can expect: Patients with comparable needs receive the same standard of care, treatment, and services throughout the care continuum. A baseline assessment of the patient's problems and is to be performed so that the appropriate level of care may be provided collaboratively by patient care providers. Analysis of the data is performed by the Registered Nurse (RN) only. The RN considers the risk and need for early intervention for prevention or referral of appropriate services. Staff notifies the medical provider of any significant changes in patient condition

1. Nursing staff failed to notify the provider when Patient #2's blood pressure (b/p) remained elevated in accordance with unit standards.

According to the Adult Patient Standards of Care policy, staff should notify the medical provider of any significant changes in patient condition.

a. Review of Patient #2's medical record revealed she was admitted with hypertension, but when her b/p elevated above her normal range, the provider was not notified to obtain orders to treat her sustained elevated b/p. Patient #2 complained of loss of vision and headache along with the elevated b/p, the RN notified the provider and Patient #2 was diagnosed with swelling of the brain.

i. The History and Physical (H&P) written on 5/6/20 at 10:11 p.m. note Patient #2 was admitted on 5/6/20 with pancreatitis (inflammation of the pancreas with upper abdominal pain) and abdominal pain with a history of daily alcohol abuse and hypertension (high b/p). Her b/p was documented as 163/94 while Patient #2 was moaning in pain. The plan was to clarify Patient #2's home hypertension medication, administer her pain medication for the pancreatitis and monitor her on the alcohol withdrawal protocol since it was unclear how much alcohol she consumed on a daily basis.

ii. Review of Patient #2's b/p measurements revealed she had a gradual increase in her b/p which was sustained at an elevated reading. Examples:

On 5/6/20 Patient #2 b/p was 163/93, 165/91 and 169/89. She was administered Hydralazine (vasodilator medication to treat high b/p) 10 mg and her b/p decreased to 135/63. Review of Patient #2's Physician Orders revealed she was ordered Hydralazine 10 mg on 5/6/20 at 8:43 p.m., to be administered as needed (PRN) for a systolic blood pressure greater than 160 or a systolic blood pressure greater than 110. The PRN Hydralazine was discontinued on 5/7/20 at 8:51 a.m.

On 5/7/20 Patient #2's b/p was noted to be 142/77, 132/96, 162/78, 169/82, 179/93, 158/84, 157/82 and 147/87. There were no provider notifications of elevated b/p or orders for a PRN medication for the elevated b/p.

On 5/8/20 Patient #2's b/p was noted to be 161/86, 146/82, 173/85, 183/93 and 171/82. There were no provider notifications of elevated b/p.

On 5/9/20, Patient #2's b/p was noted to be 163/69, 175/83, 173/90, 159/87, 169/84, 167/88, 175/87 and 177/8. There were no provider notifications of elevated b/p.

On 5/10/20, Patient #2's b/p was noted to be 180/92, 175/87, 175/95, 180/90. There were no provider notifications of elevated b/p.

iii. On 5/11/20, Patient #2's b/p was noted to be 184/98 at 2:58 a.m. and 179/94 at 3:01 a.m. The RN documented he notified the provider at 2:40 a.m. because Patient #2 had a decrease/loss in vision and headache. This was noted to be the first documentation a provider was notified of Patient #2's elevated b/p.

The RN documented Patient #2's b/p was constantly high and the patient was concerned. The RN received an order for PRN Hydralazine which was administered at 3:03 a.m. This was three days after the patient had sustained elevated blood pressure.

At 4:28 a.m., the computerized tomography scan (CT computers and rotating X-ray machines to create cross-sectional images of the body to show the soft tissues, blood vessels, and bones) revealed new edema in bilateral occipital lobes which is indicative of Posterior reversible encephalopathy syndrome (PRES a rare condition in which parts of the brain are affected by swelling).

b. Staff interview revealed the provider should have been notified of Patient #2's elevated b/p.

i. On 9/3/20 at 8:39 a.m., Registered Nurse (RN) #7 was interviewed. RN #7 stated assessments were completed on patients to make sure the patient was safe and to see if anything was going wrong. She stated routine vital signs on the unit were completed every six hours. RN #7 stated vital signs were assessed to ensure the patient was within their normal guidelines. She stated a normal b/p was 120/80, but she looked at the patient's normal b/p and would call the provider for a PRN medication if the b/p was higher than the patient's normal range. RN #7 stated the provider should be notified as soon as possible or within 15 minutes of an abnormal b/p so the provider was aware of the patient elevated b/p and could prescribed a PRN medication or advise the staff to continue to monitor. She stated it was important to notify the provider of an elevated b/p so the patient did not have a hypertensive crisis or have symptoms with the elevated b/p.

RN #7 reviewed Patient #2's medical record. RN #7 stated on 5/7/20 when her b/p went from 146/84 at 7:58 a.m., to 173/85 at 12:09 p.m., would have been a big increase and a PRN medication should have been administered or the provider should have been notified to obtain a PRN medication order to prevent the b/p from getting dangerously high. RN #7 reviewed Patient #2's b/p from 5/8/20-5/11/20 and stated her b/p remained elevated. RN #7 stated she cared for Patient #2 on 5/10/20 but she was not concerned with her b/p because her b/p had been elevated. RN #7 stated additionally, Patient #2 was in pain and on the alcohol withdrawal protocol which would elevate her b/p. RN #7 stated she had a conversation in person with the provider regarding Patient #2's b/p on 5/10/20 and was told to continue her daily scheduled b/p medication. RN #7 stated she did not document the provider notification of Patient #2's elevated b/p. RN #7 stated she should have documented provider notification.

RN #7 reviewed provider notifications from 5/7/20 to 5/11/20 and stated the provider was only notified of Patient #2's b/p on 5/11/20 at 2:40 a.m., when she had a loss of vision, headache with consistent high b/p.

c. Interviews with facility leadership revealed the provider should have been notified of Patient #2's elevated b/p.

i. On 9/2/20 at 4:03 p.m., RN Senior Manager for the Medical-Surgical Service Line (Manager) #8 was interviewed. Manager #8 stated assessments were completed on patients so staff knew how to treat the patient based on how they were responding to provider orders. She stated assessing vital signs were a piece of the puzzle to assessing a patient. Manager #8 stated a normal b/p was 110 to 130's systolic and 60 to 80's diastolic. She stated you knew a person's normal b/p by looking at their history and looking at their trends while in the hospital to obtain a baseline. Manager #8 stated if a b/p was out of the patient's normal range, she would assess for a reason and provide a PRN medication, or inform the MD within 30 minutes because it meant something was abnormal with the patient and the provider needed to be aware of and obtain a PRN order. Manager #8 stated if a b/p remained high, the patient could have a stroke, a deep vein thrombosis, pulmonary embolism, aneurysm, kidney damage, blindness or could die.

Manager #8 stated she performed an investigation of Patient #2's medical record. She stated she looked at her admission and vital signs throughout her course of treatment to paint a picture of the care Patient #2 received. Manager #2 stated the providers were adjusting her scheduled b/p medication Losartan. She stated Patient #2's b/p was 130-160's systolic and 60-80's diastolic on 5/7/20 with one abnormally high b/p of 132/96. Manager #8 stated on 5/8/20 the losartan was continued and noted on 5/9/20 Patient #2's systolic b/p was sustained in the 160-170's. Manager #8 stated she concluded on 5/10/20 there was a missed opportunity to administer a PRN dose of Hydralazine for a systolic b/p greater than 160 or diastolic b/p greater than 110. She stated Patient #2 complained of a headache and loss of vision on 5/11/20. She stated after some medication changes to her scheduled b/p medication and PRN administration of Hydralazine, Patient #2's b/p decreased on 5/12/20.

Manager #8 stated Patient #2 was going through alcohol withdrawal and had an expected elevated b/p, but determined there were a couple of times the RNs caring for the patient could have been administered Hydralazine to lower her b/p. Manager #8 stated she sent RN #13 and RN #14's manager an email for her to discuss the missed opportunity to give Hydralazine for a systolic b/p greater than 160, while she had a discussion with RN #11 and #12. She stated she did not follow up with RN #7.

Manager #8 stated she did not know after her review there was no PRN Hydralazine order. She stated when she did her review, she did not look at the discontinue date and times. Upon review of Patient #2's medication orders, Manager #8 stated the Hydralazine order was discontinued on 5/7/20 and reordered on 5/11/20. She stated, if there was no PRN order to treat a b/p of systolic greater than 160, the RNs should have notified the provider to notify of the change in condition and obtain a PRN medication order.

Manager #8 stated the only time the provider was documented as made aware of Patient #2's b/p was on 5/11/20 at 2:40 a.m., when she had a headache and loss of vision.

d. On 9/3/20 at 9:45 a.m., Provider #9 was interviewed. She stated PRES was encephalopathy where the brain was more sensitive and could get overwhelmed and have swelling. Provider #9 stated PRES was most commonly caused by an elevated b/p of systolic greater than 200 and diastolic greater than 110, or certain medications. She stated she remembered Patient #2 because she had PRES which was unusual with a sustained systolic b/p in the 180's.

e. On 9/3/20 at 9:54 a.m., the Chief Medical Officer (CMO #10) was interviewed. CMO #10 stated hypertension was elevated b/p. CMO #10 stated a patient's expected b/p was whatever their normal b/p was. CMO #10 reviewed Patient #2's medical record. She reviewed the provider Progress Notes which Patient #2's b/p was documented as 146/82 on 5/8/20, 169/84 on 5/9/20 and 180/92 on 5/10/20. CMO #10 stated as a hospitalist, she would want to be notified of a patient's b/p based on the protocols of the unit.