Failure to Communicate Resident's Condition Leads to Fatal Outcome
Summary
The deficiency involved a Nurse Practitioner (NP) who failed to communicate and collaborate with the Medical Director regarding a resident's persistent symptoms indicative of Clostridium Difficile (C. diff) infection. The resident, who had been admitted with a subdural hematoma, experienced 42 stools in 24 days, many of which were loose and foul-smelling. Despite these symptoms, the NP did not consult with the Medical Director or order a stool sample for analysis, even after the resident's Responsible Party (RP) reached out to a Gastroenterologist for advice. The NP's progress notes consistently documented the resident's loose stools but did not indicate any communication with the Medical Director. The NP prescribed banana flakes and later loperamide to manage the symptoms but did not assess the effectiveness of these treatments or consult with the Medical Director. The resident's condition worsened, leading to a high panic level white blood cell count, which was not communicated to the Medical Director. Eventually, the resident requested to be transferred to the hospital, where he was diagnosed with septic shock secondary to C. diff and subsequently passed away. Interviews with facility staff revealed a lack of a system for communication between the NP and the Medical Director regarding significant changes in residents' conditions. The Medical Director was not informed of the resident's critical lab values or the severity of his symptoms. The Director of Nursing (DON) was also unaware of the communication protocols between the NP and the Medical Director, assuming that changes were reported as needed. This lack of communication and oversight contributed to the resident's deteriorating condition and eventual death.
Removal Plan
- The Medical Director will review the provider notes for all residents with a change in condition that were seen by any of the Nurse Practitioners and/or Physician Assistants. Any new orders or suggestions made by the Medical Director will be communicated to the Nurse Practitioner/Physician Assistant and the Director of Nursing for follow-up.
- The Medical Director educated all Providers working with the facility on the clostridium difficile protocol. The protocol indicates that residents with three or more watery or loose stool in a 24 hour time span should have a medication review to ensure laxatives are not contributing to the loose stool. If the loose stool does not resolve within 24 hours of the laxatives being stopped or the resident was not receiving laxatives, a clostridium difficile test will be performed. The NP was included in the provider education.
- The Director of Nursing was educated by the Regional Director of Clinical Services on providing the Medical Director with a list of residents that were seen by a Nurse Practitioner and/or Physician Assistant in the previous seven days, due to a change in condition, weekly for the Medical Director to review.
- The Director of Nursing will review all progress notes weekly to determine the residents that were seen in the past 7 days for a change in condition.
- The Medical Director will review the Nurse Practitioner and/or Physician Assistant progress notes weekly and communicate any suggestions to the Nurse Practitioners and/or Physician Assistants and the facility.
- The Regional Director of Clinical Services communicated the new review process to the provider groups Nurse Practitioners and/or Physician Assistants.
- The Medical Director was informed of the new review process by the Director of Nursing and is in agreement with the system of communication and collaboration.
Penalty
Resources
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The facility did not provide documentation that a physician personally completed or participated in required admission examinations for several residents with complex medical conditions. Instead, a CNP conducted these assessments via telemedicine, and staff interviews confirmed that the physician's involvement was not documented, with most communication occurring virtually or by phone.
A resident with a history of gastrointestinal bleeding and recent fractures was not properly managed for anticoagulation therapy due to a lack of communication between the NP and the Medical Director. The NP ordered aspirin, which was discontinued due to an allergy, and failed to consult the Medical Director directly. The resident developed signs of DVT, and a delayed doppler study led to hospitalization for blood clots in both legs.
A resident with a history of vascular dementia and other health issues suffered a femur fracture after a fall. The NP failed to consult with the Medical Director, delaying appropriate medical intervention. The resident's pain became unmanageable, leading to a hospital transfer and surgery. The delay in treatment increased the risk of complications.
The facility did not have a policy or procedure for physician delegation of tasks to physician assistants, nurse practitioners, or clinical nurse specialists. This deficiency was identified during a policy review, and the administrator confirmed the absence of such a policy, potentially affecting all 69 residents.
Lack of Physician Documentation and Delegation in Admission Examinations
Penalty
Summary
The facility failed to provide evidence that the physician did not delegate tasks to non-physician providers that were required to be completed personally by the physician. For four residents admitted from short-term general hospitals, medical record reviews showed that there were no progress notes written by the physician, who also served as the facility's Medical Director, documenting participation in the admission examinations. Instead, admission evaluations were completed by a Certified Nurse Practitioner (CNP) via telehealth or telemedicine, with no documentation of the physician's involvement in these assessments. Interviews with facility staff, including the Director of Nursing (DON), an LPN, and the CNP, confirmed that the physician often participated in meetings and resident visits via telephone or telemedicine due to personal circumstances. However, there was no documentation in the residents' records to verify the physician's participation in the admission process. The CNP also stated she was unaware of any law prohibiting her from completing initial visits via telemedicine, and verified that visits were conducted virtually if indicated in the progress notes.
Failure to Communicate and Collaborate on Anticoagulation Therapy
Penalty
Summary
The facility's Nurse Practitioner (NP) failed to communicate and collaborate with the Medical Director after a resident's Responsible Party (RP) raised concerns about the resident not receiving anticoagulation therapy following a fall that resulted in multiple fractures. The NP ordered aspirin, which was later discontinued due to the resident's allergy and history of gastrointestinal bleeding. Despite instructing the Assistant Director of Nursing (ADON) to consult the Medical Director, the NP did not reach out to the Medical Director herself, leading to a lack of timely intervention. The resident, who had a history of gastrointestinal bleeding and was immobile due to fractures, showed signs of increased pain and swelling in the left lower extremity, indicative of a potential deep vein thrombosis (DVT). The NP evaluated the resident and recommended a venous doppler study, but the study was not available until the following week. The resident's condition worsened, and she was eventually transferred to the hospital, where she was diagnosed with blood clots in both lower extremities and required anticoagulation and hospitalization. The Medical Director was not informed of the resident's condition or the delay in the doppler study. Had the Medical Director been notified, he would have ordered a timely doppler study and potentially initiated anticoagulation therapy. The lack of communication and collaboration between the NP and the Medical Director resulted in a delay in appropriate medical intervention, leading to the resident's hospitalization.
Removal Plan
- The Administrator met with the Medical Director and NP and reviewed the expectations of the MD and NP communicating and collaborating with each other. NP should consult with MD in any circumstance regarding medical management needing a higher level of care or beyond his/her scope of practice.
- The agreement between the providers was reviewed, no changes were made to the provider agreement.
- The NP was educated on when she should consult with the MD based on review of scope of practice and collaborative provider agreement.
- The Medical Director/Senior partner of provider group educated the MD and all attending Physicians and on call that the NP should consult with MD in any circumstance regarding medical management needing a higher level of care or beyond his/her scope of practice defined by the North Carolina Medical Board and North Carolina Board of Nursing.
- The Medical Director informed the Administrator and DON that the MD and NP will have weekly meetings to ensure ongoing collaboration, and the MD will report any results of the meetings to Administrator and DON.
Failure in Communication and Collaboration Delays Resident's Fracture Treatment
Penalty
Summary
The deficiency involved a failure in communication and collaboration between a Nurse Practitioner (NP) and the Medical Director regarding the medical management of a resident who suffered an acute nondisplaced transverse left femur fracture following an unwitnessed fall. The NP did not consult with the Medical Director before deciding that the resident was probably not a surgical candidate and attempted to treat the resident in-house. This lack of communication resulted in the Medical Director being unaware of the fracture until several days later, delaying appropriate medical intervention. The resident, who had a history of vascular dementia, muscle weakness, and other significant health issues, experienced an unwitnessed fall and was initially assessed with no injuries noted. However, the resident later reported pain, and an x-ray confirmed a fracture. Despite this, the NP chose to manage the condition conservatively without consulting the Medical Director, who only became aware of the fracture days later when the resident's pain became unmanageable. The delay in appropriate medical management led to the resident being sent to the hospital for surgery only after the Medical Director intervened. The resident subsequently experienced complications, including an aspiration event resulting in acute hypoxic respiratory failure while hospitalized. The deficiency affected the resident's timely access to necessary orthopedic care and increased the risk of further complications.
Removal Plan
- The MD reviewed the NP's notes for the previous 30 days, including the on-call providers, to ensure the plan of care was appropriate for the residents. Any opportunities identified during this audit were corrected by the MD.
- The Regional Director of Clinical Services, Nurse Practitioner, Medical Director, and the Director of Nursing reviewed Resident #1's plan of care and collaborated on what the best course of treatment should have been for the resident.
- The Regional [NAME] President educated the Medical Director, NPs, and covering providers on collaborating/consulting following a fracture and/or a significant change of condition. The Medical Director, Nurse Practitioners and covering providers will collaborate 3 times a week via phone, in-person, or virtual to discuss the plan of care for the residents that have obtained a fracture or a significant change in condition.
- The Regional [NAME] President educated The Director of Nursing and the Administrator to participate in the meeting.
- The Medical Director reviewed the guidelines for how the Nurse Practitioners and other covering providers to communicate with the Medical Director. The Medical Director and Regional [NAME] President discussed this agreement with the NPs and other providers.
- The Regional Director of Clinical Services educated the Nurse Management Team and the Director of Nursing regarding the nurse practitioners' notes, including on call to ensure communication and collaboration is completed. The Director of Nursing, unit managers, staff development nurse and Assistant Director of Nursing will review and print the nurse practitioner notes, including the on-call providers daily and place them in the Medical Director's communication book. When the Medical Director is not in the facility, he will receive an electronic HIPAA compliant copy of the medical progress notes generated each day. Any new hires, including agency staff, will receive education prior to the start of their shift via telephone or in person.
- The Administrator will be responsible to ensure implementation of this immediate jeopardy removal for this alleged non-compliance.
Lack of Physician Delegation Policy
Penalty
Summary
The facility failed to develop a policy and procedure for the delegation of tasks by physicians to physician assistants, nurse practitioners, or clinical nurse specialists. This deficiency was identified during a review of facility policies on 9/6/24, which revealed the absence of a procedure for physician delegation of tasks. The administrator confirmed the lack of such a policy or procedure when interviewed on the same day at 5:22 p.m. This oversight had the potential to affect all 69 residents residing at the facility.
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