Failure to Notify Physician of Sustained Abnormal Vital Signs
Penalty
Summary
The facility failed to assess and notify a resident's medical doctor when the resident exhibited sustained tachycardia and tachypnea. The resident, who had a history of chronic respiratory failure, tracheostomy dependence, pneumonia, and sepsis, was admitted with severely impaired decision-making capacity. On the day of the incident, the resident's respiratory rate was consistently above 30 breaths per minute and heart rate above 100 beats per minute for several hours, as documented in the flowsheets. Despite these abnormal vital signs, there was no immediate assessment or notification to the medical doctor. Nursing staff, including an LVN and an RN, were aware of the elevated vital signs but did not notify the physician until several hours after the onset. The RN acknowledged being too busy to address the situation promptly, and the LVN did not call the physician earlier. The facility's policies required immediate assessment and physician notification in the event of abnormal vital signs, but these protocols were not followed. As a result of the delayed response, the resident's condition was not managed in a timely manner, and the resident was eventually transferred to a general acute care hospital for evaluation. Interviews with nursing staff and the Director of Nursing confirmed that the abnormal vital signs should have prompted earlier physician notification and intervention, in accordance with facility policy.