Delayed Physician Notification and Response for Change in Condition
Penalty
Summary
The facility failed to promptly implement and ensure physician notification and response for a resident who exhibited new onset signs and symptoms of a urinary tract infection (UTI). The resident, who had a history of diabetes mellitus, heart failure, and renal failure, began experiencing pain, burning, urgency, and increased incontinence with urination over a weekend. Despite repeatedly informing nursing staff of her symptoms and requesting intervention, the resident did not receive timely assessment or physician notification. Documentation shows that a change in condition assessment was completed, but the physician was not notified until the following Monday, and a urine sample was not collected until the next day. The resident endured unresolved pain and discomfort for several days, and there was a lack of ongoing assessment, including vital signs and pain evaluation, during this period. Additionally, the facility failed to notify a physician in a timely manner for another resident with elevated blood sugar levels. This resident, who had diagnoses including diabetes mellitus and was receiving daily insulin injections, had multiple blood glucose readings significantly above the normal range. There was no documentation of physician notification regarding these elevated levels, despite facility policy requiring such action when blood sugars are outside of parameters. The care plan for this resident also lacked specific blood sugar parameters, and the resident was not assessed or reported to the physician until the following day. Interviews with staff, including the DON, confirmed that the expected protocol was not followed in both cases. The facility's own policies require timely physician notification and thorough documentation when a resident experiences a change in condition or abnormal lab results. However, in both instances, there was a delay in notifying the physician and implementing appropriate interventions, resulting in delayed care for the affected residents.