Failure to Provide Timely Emergency Physician Services
Summary
The facility failed to ensure that emergency physician services were utilized for a resident who was moderately cognitively impaired and had multiple diagnoses, including morbid obesity, anxiety disorder, metabolic encephalopathy, COPD, and chronic respiratory failure. After returning from a hospital stay, the resident had not voided for approximately 13 hours, and facility staff made several attempts to contact the resident's physician and the facility's on-call medical provider without success. The facility's nurse practitioner was unable to provide an order for catheterization because the resident was not under their care. The Director of Nursing acknowledged that there was no plan in place for residents under the care of the independent physician if he did not respond to calls. The resident eventually received a straight catheterization, which relieved 600cc of urine, indicating significant urinary retention. The lack of timely physician response and the absence of a contingency plan for emergency care contributed to the deficiency, as the resident did not receive prompt medical intervention for a potentially serious condition.
Penalty
Resources
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A resident on blood thinners experienced a fall that reopened an existing wound, but the LPN on duty did not perform neurochecks or immediately notify a provider, instead documenting the event in a communication book for review the next day due to lack of on-call coverage. The next morning, an RN reported the resident had a severe headache and altered cognition and expressed concern for a possible brain bleed, confirming that neurochecks and timely provider notification had not occurred. Later, frank blood was noted in the toilet without immediate physician notification, despite the DON’s expectation that such findings, along with the resident’s anticoagulant use and cognitive impairment, should trigger neurochecks, prompt provider contact, and possible ED transfer. The DON and RN reported that the facility had not maintained 24-hour on-call physician services for several years, contrary to facility policy requiring continuous physician availability for emergencies.
A resident with a critically low potassium level had a lab result communicated to nursing staff overnight, but repeated attempts to reach the on-call physician were unsuccessful. Nursing staff did not escalate the issue to the medical director or backup provider, and the attending physician was not made aware of the critical result. Facility policy and expectations for 24-hour physician coverage were not met.
A resident with ALS, diabetes, and depression experienced cough, congestion, and fear of choking overnight. The nurse notified the physician by text about some symptoms but did not communicate the resident's fear of choking or shortness of breath. The physician did not respond for over eight hours, and the nurse did not escalate the issue to the DON or Medical Director as required by policy. The resident's family later called 911, and the resident was hospitalized with pneumonia and hypoxia.
A resident experiencing abdominal pain and emesis was assessed by an LPN, who attempted to contact the on-call physician via telehealth but did not receive a timely response. While waiting for a callback, the resident's representative was informed and transported the resident to the ER without a physician's order. The resident was later admitted to the hospital for bowel obstruction and hypotension. The facility administrator acknowledged the on-call provider did not respond in a reasonable timeframe.
A resident with a complex medical history, including TBI, hydrocephalus with shunt, tracheostomy, and quadriplegia, experienced a fall and subsequent decline in condition. Nursing staff were unable to reach the assigned physician for over four hours despite multiple attempts, and did not transport the resident to the ER in a timely manner. The physician was eventually reached and instructed staff to send the resident to the ER, resulting in a delayed transfer.
A resident with a history of bipolar disorder and intact cognition exhibited erratic behaviors after ECT treatment, including undressing in public and urinating on the floor. Despite these changes, the facility failed to notify a physician or conduct an assessment during the night, delaying emergency care until the following morning.
Failure to Provide 24-Hour On-Call Physician Coverage and Post-Fall Assessment
Penalty
Summary
The deficiency involves the facility’s failure to provide or arrange 24-hour on-call physician services and to ensure timely provider notification and appropriate post-fall assessment for a resident on blood-thinning medication. After the resident, who was new to the facility and taking blood thinners, fell at 7:15 p.m. on 2/4/26, an LPN assessed the resident, noted that an existing wound on the resident’s bottom had reopened, and applied a dressing. However, neurochecks were not performed, and the provider was not notified immediately. Instead, the LPN documented the fall in a communication book for the provider to review during rounds the next day, stating that there was no on-call provider available. The facility’s own policy required 24-hour physician coverage for emergencies, including contacting the primary physician first, then the on-call physician, and, if necessary, the medical director, and transporting the resident to the ED if no physician was reachable and immediate assessment was required. On the following morning, an RN caring for the same resident reported that the resident requested transfer to the ED for a headache rated 7/10 and expressed concern for a possible brain bleed due to the recent fall, use of blood thinners, and altered cognition. The RN confirmed that neurochecks had not been performed after the fall and that the provider had not been notified immediately. The DON stated that, per facility expectations, staff should assess for injury, take vital signs, initiate neurochecks, notify the provider, inform the family, and document in risk management after a fall, and confirmed that these steps were not followed for this resident, who also had moderate cognitive impairment. At 2:05 a.m. on 2/5/26, frank blood was observed in the toilet, but staff still did not notify the physician immediately, despite the DON’s statement that this finding should have prompted an ED transfer due to increased risk of bleeding and that normal vital signs alone could not rule out internal bleeding. The DON and RN both confirmed that the facility had not had 24-hour on-call physician coverage for the past four years, and local providers did not round at the facility, have access to records, or provide on-call coverage, affecting all residents.
Failure to Provide 24-Hour On-Call Physician Services for Critical Lab Result
Penalty
Summary
Facility staff failed to provide 24-hour on-call physician services for one resident when a critical laboratory result was received. The resident had a potassium level of 2.9 mEq/L, which is below the normal range. Nursing staff documented that they attempted to contact the on-call physician multiple times during the early morning hours, but did not receive a return call. The progress notes indicate that the on-call physician was not reached despite repeated attempts, and the issue was not escalated to the medical director or backup provider as per facility expectations. Interviews with administrative and clinical staff confirmed that nurses are expected to reach an on-call physician at all times and should escalate to the medical director if unable to do so. The attending physician stated that there is always a backup provider available and that the on-call service has their contact information. He also confirmed he was not made aware of the resident's critical potassium level and would have ordered immediate treatment if notified. No additional documentation or policy regarding 24-hour physician coverage was provided prior to the survey exit.
Failure to Ensure Timely Physician Response to Change of Condition
Penalty
Summary
A deficiency occurred when the facility failed to ensure a physician responded in a timely manner to a resident's change of condition. The resident, who had diagnoses including amyotrophic lateral sclerosis (ALS), diabetes type 2, and major depressive disorder, began experiencing symptoms such as headache, cough, congestion, and expressed fear of choking during the night shift. The resident was cognitively intact and able to communicate his symptoms and concerns, including shortness of breath and anxiety about lying down due to fear of choking. The nurse on duty administered medications for headache and sore throat, and documented the resident's complaints, but only notified the physician via text message about the cough and congestion, omitting the resident's fear of choking and shortness of breath. The nurse sent text messages to the resident's physician at two points during the night shift, but the physician did not respond until over eight hours later, after the shift had ended. The nurse did not escalate the situation by contacting the Director of Nursing (DON) or the Medical Director when the physician failed to respond, as required by facility policy. The resident continued to experience symptoms and anxiety throughout the night, remaining upright to ease breathing, and felt that the nursing staff did not believe the severity of his symptoms. The following morning, the resident's family called 911, and the resident was transferred to a general acute care hospital, where he was diagnosed with pneumonia secondary to COVID-19 and hypoxia. Interviews with the resident, the nurse, the physician, and the DON confirmed that the physician was not informed of the full extent of the resident's symptoms, particularly the fear of choking and shortness of breath. The physician stated that he would have ordered additional interventions if he had been made aware of these symptoms. Facility policy required immediate escalation to the DON or Medical Director if the attending physician could not be reached, but this was not done. Documentation and interviews confirmed the delay in physician response and the lack of appropriate escalation.
Failure to Ensure 24-Hour Physician Availability for Emergency Care
Penalty
Summary
The facility failed to ensure the provision of physician services 24 hours a day in the event of an emergency for one resident. On the evening in question, a resident complained of severe abdominal pain and emesis, and the nurse on duty assessed the resident, determining that the resident was not in distress at that time. The nurse attempted to contact the on-call physician through the telehealth service but did not receive a timely response after calling twice. While waiting for a response, the resident's representative was informed of the situation and ultimately transported the resident to the emergency room without a physician's order, as the nurse was still awaiting a callback from the practitioner. Documentation in the medical record indicated that the resident was later admitted to the hospital for a bowel obstruction and hypotension. Staff interviews confirmed that the nurse took the resident's complaint seriously and followed protocol by attempting to contact the on-call provider, but the lack of timely physician response led to the resident being transported by the representative. The facility administrator acknowledged that the on-call practitioner should have been available and responded in a reasonable timeframe.
Delay in Emergency Physician Response and Resident Transfer
Penalty
Summary
The facility failed to ensure the availability of a physician for emergency care for one resident who experienced a fall and subsequent change in condition. The resident, a male with a history of traumatic brain injury, subdural hematoma, decompression craniotomy, post-traumatic hydrocephalus with a shunt, tracheostomy, PEG tube, and quadriplegia, fell from bed while being changed by a CNA. Following the fall, the resident exhibited a drop in oxygen saturation and became increasingly lethargic, eventually becoming unresponsive to painful stimuli and verbal questions. Despite these significant changes in condition, nursing staff were unable to reach the assigned physician for over four and a half hours, making multiple attempts to contact him directly and through the physician exchange service. During this period, staff did not transport the resident to the emergency room in a timely manner, despite the inability to reach the physician and the resident's deteriorating condition. The physician was eventually reached after more than four hours and instructed staff to send the resident to the ER, at which point 911 was called and the resident was transferred. Interviews with staff and the DON confirmed the delay in reaching the physician and uncertainty about the appropriate steps to take when the physician could not be contacted, especially as the physician was reportedly out of the country at the time.
Failure to Provide Timely Emergency Care for Resident with Behavioral Changes
Penalty
Summary
The facility failed to provide timely emergency services for a resident, identified as Resident #8, who exhibited a significant change in behavior following an electroconvulsive therapy (ECT) treatment. The resident, who had diagnoses of bipolar disorder, anxiety, and depression, and was noted to have intact cognition, began displaying erratic behaviors such as urinating on the floor and undressing in public areas. Despite these changes, there was no documentation of an assessment or physician notification during the night when the behaviors were first observed. Staff interviews revealed that the resident's behavior was notably different from his usual demeanor, which was typically calm and sociable. Staff members reported that the resident appeared disoriented and behaved inappropriately, yet the facility did not notify a physician or send the resident for evaluation until the following morning. The Director of Nursing acknowledged that a change in mental status should prompt immediate provider notification, which did not occur in this instance.
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