Failure to Follow Physician Notification Protocol for Change in Condition
Penalty
Summary
The facility failed to follow its established protocols for notifying a physician of a resident's change in condition. According to facility policy, if a tele-health physician does not respond within five minutes, staff are required to re-initiate the consult or contact the medical director for assistance. On the date in question, a resident with a nephrostomy tube and a history of renal insufficiency was observed to have dark red drainage from the tube, along with complaints of nausea and left flank pain. The resident's vital signs were recorded, and both the RN supervisor and charge nurse were notified. A call was placed to the tele-health physician, but no further attempts to contact a physician were documented after the initial call. The tele-health physician did not return the call until over an hour later, during which time the resident's family requested hospital transfer and called 911. Interviews with the DON and Nursing Home Administrator confirmed that staff did not follow the required steps outlined in the facility's policy when the physician did not respond promptly. This failure to adhere to protocol resulted in a delay in physician notification regarding the resident's change in condition.