Delay in Physician Notification Following Change in Resident Condition
Penalty
Summary
A deficiency occurred when the facility failed to ensure timely notification of the attending physician following a significant change in condition for one resident. The resident, who had a history of chronic respiratory failure, seizure disorder, traumatic brain injury, and was in a vegetative state, developed a fever and increased thick, dark yellow secretions late in the evening. Nursing documentation indicated that these symptoms were observed at 11 p.m., but there was no record of the attending physician being notified at that time. The attending physician was eventually notified approximately six hours later, in the early morning, after the resident continued to exhibit symptoms including fever, increased secretions, excessive coughing, and vomiting. At that point, the physician provided new orders for diagnostic tests and treatments, including blood cultures, laboratory tests, intravenous fluids, and antibiotics. Both the registered nurse and the director of subacute care acknowledged during interviews that the delay in physician notification was not in accordance with facility policy and could result in delayed care. Facility policy required prompt notification of the physician in the event of an acute medical change, with documentation of all attempts to notify and follow-up actions. The nurse in charge was responsible for ensuring the physician and family or legal representative were notified prior to the end of the shift when a change in condition was noted. In this case, the delay in notification was confirmed through record review and staff interviews, constituting a failure to follow established procedures for timely communication regarding changes in a resident's condition.