Failure to Notify Physician of Significant Change in Condition for Resident on Anticoagulant Therapy
Penalty
Summary
Licensed nursing staff failed to promptly notify the attending physician or physician assistant of a resident's significant change in condition, despite clear physician orders and care plan instructions to do so. The resident, who had a history of Parkinsonism, dysphagia, chronic kidney disease, hypertension, orthostatic hypotension, and was on long-term anticoagulant therapy (Eliquis), experienced multiple concerning symptoms including altered level of consciousness, shortness of breath, hypotension, and three episodes of coffee-ground emesis over a period of several hours. These symptoms were documented in the resident's records and observed by both licensed nurses and CNAs, but the physician was not notified until after emergency medical services (EMS) were called and the resident was transferred to the hospital. The facility's records and staff interviews revealed that the resident's condition deteriorated over several hours, with repeated episodes of vomiting and declining vital signs. Despite the care plan and physician orders requiring monitoring for adverse reactions to anticoagulant therapy and immediate physician notification for symptoms such as vomiting, bleeding, or changes in mental status, the licensed nurses did not contact the physician or physician assistant during the critical period. Staff interviews indicated a lack of recall regarding the specifics of the resident's symptoms and the timing of events, and documentation was incomplete or inconsistent with observed events. The failure to notify the physician in a timely manner resulted in a delay in diagnosis, care, and emergency interventions for the resident. EMS was eventually called when the resident's condition became critical, and upon arrival, EMS found the resident in respiratory failure with evidence of coffee-ground emesis. The resident was transferred to the hospital, where resuscitation efforts were unsuccessful, and the resident was pronounced dead. The deficiency was identified by surveyors as an Immediate Jeopardy situation due to the facility's noncompliance with requirements for physician notification of significant changes in condition.
Removal Plan
- The DON and Assistant DON (ADON) notified the nursing staff (all licensed nurses) of findings outlined in the IJ and conducted in-services for all nursing staff (21 licensed nurses and 42 certified nursing assistants (CNAs) regarding the Change of Condition policy. The training covered: a. Utilizing the Interact early warning toll-stop and watch technique to report any possible resident's changes in condition. b. Utilizing the SBAR form to record the change of condition to ensure accuracy and completeness that included current vital signs, detailed description of the identified situation, any drainage observed, interventions provided including physician notification. c. The anticoagulant monitoring which includes but not limited to: discolored urine, black tarry stools, nausea/vomiting or diarrhea, bruising/bleeding, abnormal vital signs, shortness of breath, and change in mental status. d. Timely physician notification for the onset of changes in condition, including the identified signs related to anticoagulant adverse reaction monitoring. The DON emphasized the importance of notifying the physician upon identification of the situation to avoid any possible delay.
- The facility pharmacist was contacted and will complete in-service to licensed nurses regarding black box warning. During the in-service, the pharmacist will educate the following areas: a. Following physician's orders/instructions for residents with medications labeled black box warning, such as specific monitoring, laboratory tests, etc., b. Creating and implementing the care plan c. Notifying the physician if any identified signs of adverse reaction
- The DON notified the staff who could not complete the in-services must receive an in-service upon their return before their shift.
- The facility notified the facility Medical Director of the IJ and the IJ Removal Plan. The Medical Director reviewed and approved the IJ removal plan.
- The ADM completed the Quality Assurance and Performance Improvement (QAPI) Plan for identifying and notifying the physician of resident change of condition. The Medical Director will review the QAPI program for change of condition/physician notification every month and assist the facility in adjusting the measures as necessary.
- LVN [1] assigned to Resident 1 received disciplinary action pending investigation. The DON provided one-to-one in-service with LVN 1 regarding physician notification prior to the suspension.
- A total of 28 current residents are receiving anticoagulant therapy. All 28 residents who have anticoagulant orders have monitoring for adverse reactions in the electronic medication administration record.
- The DON will conduct a monthly in-service for nursing staff (licensed nurses and CNAS) regarding change in condition for three months.
- The DON and/or ADON will review the change of condition daily, to ensure timely physician notification of any onset signs or symptoms.
- The DON created a change of condition monitoring log, which includes the physician notification of any changes. The DON notified nursing staff of the monitoring process and will document the findings and corrective action in the monitoring log for three months. If any issues are identified, the DON will extend the monitoring period for an addition of three months.
- The DON/RNS will make daily rounds to ensure that any resident changes in condition is being reported and addressed. The DON/RNS would provide a one-to-one inservice if any issues identified.
- The facility initiated a QAPI for physician notification of changes in condition to address the findings outlined in the IJ template. The facility will review the progress every month for 3 months and adjust the measures as needed to ensure an effective and consistent plan.