Failure to Notify Physician and Emergency Contact of Resident Condition Changes
Penalty
Summary
The facility failed to notify a resident's emergency contact and physician regarding the resident's refusal to provide a urine specimen for urinalysis, as well as failed to notify the physician of a low blood sugar result as ordered. The resident in question had moderate cognitive impairment and a history of cerebral infarction, with physician orders in place to notify the provider if blood sugar was less than 60 or greater than 250, and to obtain a urinalysis. Documentation showed that the resident refused to provide a urine specimen, but there was no record that the physician or emergency contact were informed of this refusal, nor was there documentation that another attempt was made to collect the specimen. Additionally, when the resident's blood sugar was recorded at 57, insulin was held as per protocol, but there was no documentation that the physician was notified of this low blood sugar, despite an order requiring such notification. Interviews with staff confirmed that the notifications were not made and not documented, and the facility's policy required immediate sharing of changes in a resident's condition or treatment with the resident, their representative, and the attending physician.