| 11 |
WASHINGTON CTR FOR AGING SVCS |
95014 |
2601 18TH STREET NE |
WASHINGTON |
DC |
20018 |
2019-07-30 |
658 |
D |
0 |
1 |
BMNI11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Medpass observation and interview for one (1) of 56 sampled residents, the facility staff failed to provide care in accordance with professional nursing standards as evidenced by the staff was observed using the blood pressure machine incorrectly to measure one (1) resident's blood pressure. Resident #14. Findings included . According to the American Heart Association: Accurate measurement of blood pressure is essential to classify individuals, to ascertain blood pressure-related risk, and to guide management. Selection of the correct cuff size, and proper patient positioning if accurate blood pressures are to be obtained . In view of the consequences of inaccurate measurement, regulatory agencies should establish standards to ensure the use of validated devices, routine calibration of equipment, and the training and retraining of manual observers. Retrieved from: www.ahajournals.org/doi/full/10.1161/01.HYPXXX XXX .8e Resident #14 was admitted to the facility on (MONTH) 27, (YEAR), with diagnoses, which include [MEDICAL CONDITION], Neoplasm of Prostate, Cardiomegaly, Hypertension, [MEDICAL CONDITION], and Coronary [MEDICAL CONDITION]. A review of the Quarterly Minimum Data Set (MDS) dated (MONTH) 3, 2019, Section C0500 (BIMS (Brief Interview for Mental Status) Summary Scores) of 12 Moderately impaired which indicates, Resident unable to make decisions. During Med pass observation on (MONTH) 23, 2019, at 8:55 AM, Employee #10 was observed using the blood pressure machine incorrectly to measure Resident # 14's blood pressure and to walk away out of the room, leaving the resident's medication at the bedside prior to administering the resident his medication. The employee used an automatic digital blood pressure machine provided by the facility for measuring residents blood pressure. Observation showed the blood pressure machine had a problem measuring Resident #14's blood pressure. Employee#17 removed and reapplied the digital upper arm blood pressure cuff to the resident's forearm to measure the resident's blood pressure. At the time of the observation, Employee #17 was asked what is the process used for applying a blood pressure cuff to measure the blood pressure. Employee #17 was able to verbalize the process used to measure the resident blood pressure and concluded that the machine was having a problem. At the time of the observation, Employee #, 17 did not recheck the resident's blood pressure for accuracy. A face-to-face interview was conducted on (MONTH) 23, 2019, at approximately 10:15 AM, with Employee #18 and Employee #17. Both employees acknowledged the findings. |
2020-09-01 |