Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
A deficiency occurred when the facility failed to notify the physician in a timely manner regarding a significant change in condition for a resident. The resident had multiple diagnoses, including pleural effusion, acute respiratory syncytial virus, hypertensive heart disease with heart failure, endocarditis, dementia, cardiomegaly, and edema. On assessment, the resident presented with pitting edema in both lower extremities, with the left leg showing 2+ edema and the right leg 1+ edema. The resident also complained of mild pain in the lower legs, which worsened on palpation, and was observed to be short of breath with expiratory wheezes. The nurse's note documented these findings, but there was no evidence in the record that the physician was notified promptly about these changes. Interviews with nursing staff and the Director of Nursing confirmed that the physician should have been contacted immediately when the resident exhibited increased edema, pain, and respiratory symptoms. The facility's policy also required timely notification of the physician for any change in condition to ensure appropriate interventions. The lack of timely physician notification in this case constituted a failure to follow established protocols for resident care.