Failure to Notify Physician of Significant Change in Resident Condition
Penalty
Summary
The facility failed to notify the attending physician when a significant change in condition occurred for one resident. The resident, who had a history of chronic respiratory failure, anxiety disorder, and dependence on a respiratory ventilator, was comatose and fully dependent on staff for care. On the date in question, the resident experienced tachycardia and a low-grade temperature, which constituted a change of condition. The resident was subsequently transferred to a general acute care hospital at the request of the responsible party, who was present and aware of the transfer. Upon review of the resident's records and interviews with facility staff, it was determined that no Change of Condition (COC) form was completed for this event, and there was no documented evidence that the physician was notified of the resident's change in status. The facility's policy requires immediate notification of the physician and responsible party in the event of a significant change in condition. The Director of Staff Development confirmed that the lack of a completed COC form could result in missed communication to required parties, and acknowledged that the physician had not been notified as required by policy.