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Based on record reviews and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care for each patient as evidenced by failure of the nursing staff to notify the attending physician of elevated blood pressure per standing orders for 1 (#1) of 5 (#1-#5) patient records reviewed.

Findings:

Review of the policy titled Vital Signs, Policy Number 3.23, dated January 2021 revealed in part: 2. Vital signs are taken BID (two times per day) unless otherwise specified by the physician. 5. The nurse is responsible for reviewing vital signs when taken by the MHT. Abnormal vital signs are re-checked by the registered nurse manually an appropriate action is taken. 6. Abnormal vital signs are reported to the physician. The nurse must document physician notification and his response in the nurses notes. Abnormal Parameters: b. Systolic greater than 160 or less than 100. c. Diastolic greater than 90 or less than 60.

Review of the medical record for patient #1 revealed the patient was PEC'd on 10/17/2022 and admitted to the hospital on 10/18/2022 for Depression with Suicidal Ideation. Patient #1 had a history of CHF, CAD, HTN, MI, HLD, CKD, Migraines, Parathyroid Ca, and Seizure Disorder.

Review of the Physicians Orders dated 10/18/2022 for patient #1 revealed an order for Catapress 0.1 mg tab (Clonidine) 0.1 mg PO PRN Q6H.

Review of the vital sign documentation for patient #1 dated 10/18/2022 at 7:01 p.m. revealed a blood pressure of 170/92, with no documentation that the physician was notified. Vital signs documented on 10/19/2022 at 11:05 a.m. revealed the patients' blood pressure was 200/98 with no documentation that the physician was notified.

Interview on 12/05/2022 at 2:30 p.m. with S7LPN confirmed that the physician was not notified for the elevated blood pressure on 10/18/2022 or 10/19/2022.

Based on record review and interview, the hospital failed to ensure medications were administered in accordance with the physician's standing orders for elevated blood pressure for 1 (#1) of 5 (#1-#5) sampled patients records.

Findings:

Review of the policy titled Vital Signs, Policy Number 3.23, dated January 2021 revealed in part: 2. Vital signs are taken BID (two times per day) unless otherwise specified by the physician. 5. The nurse is responsible for reviewing vital signs when taken by the MHT. Abnormal vital signs are re-checked by the registered nurse manually an appropriate action is taken. 6. Abnormal vital signs are reported to the physician. The nurse must document physician notification and his response in the nurses notes. Abnormal Parameters: b. Systolic greater than 160 or less than 100. c. Diastolic greater than 90 or less than 60.

Review of the Physicians Orders dated 10/18/2022 for patient #1 revealed an order for Catapress 0.1 mg tab (Clonidine) 0.1 mg PO PRN Q6H.

Review of the vital sign documentation for patient #1 dated 10/18/2022 at 7:01 p.m. revealed a blood pressure of 170/92. There was no documentation on the MAR that any medication was given.

Interview on 12/05/2022 at 2:30 p.m. with S7LPN confirmed there was no medication given for the elevated blood pressure on 10/18/2022.