Client #1 had been hospitalized for 10 days following a heart attack.
Client #1's plan of care stated, "Skilled nurse (SN) check vital signs (every) visit and report to MD (Medical Doctor) if above or below the following parameters: SB/P (systolic blood pressure) greater than 180 and less than 90, DB/P (diastolic blood pressure) greater than 90 and less than 60."
At one visit, the client's blood pressure was 158/92, which was out of the given reporting parameters. The clinical record did not contain any evidence that the abnormal blood pressure was reported as ordered to the physician.
Three weeks later, the client's blood pressure was 149/95. The clinical note did not contain any evidence that the physician was notified.
In an interview, the LVN stated that "I didn't realize I was supposed to report diastolic pressures above 90. The client told me her doctor only worries about it if it's over 100.