Failure to Notify Physician and Family After Resident's Change in Condition
Penalty
Summary
A deficiency occurred when a nurse failed to immediately notify a resident's physician and representative after a significant change in the resident's condition. The resident, an elderly female with chronic atrial fibrillation, repeated falls, and dementia, was found by a CNA to be experiencing agonal breathing, cold skin, fixed pupils, no urine output, and lethargy. The nurse on duty, LVN A, assessed the resident and noted these symptoms, but did not contact the physician or the resident's family, instead choosing to monitor the resident throughout the remainder of her shift. LVN A stated that she believed the resident was actively dying and, due to the resident's DNR status and a social worker note indicating the family did not want to be called in the middle of the night unless it was an emergency, she did not notify anyone. However, interviews with other staff, including the DON, another LVN, and the administrator, confirmed that the resident was not on hospice and that the nurse should have notified the physician and the family immediately upon recognizing the change in condition. The oncoming nurse, LVN C, upon receiving report and assessing the resident, called 911, notified the nurse practitioner, the family, and the DON. The facility's policy required prompt notification of the physician and resident representative in the event of a significant change in condition. The failure to follow this protocol was confirmed through interviews and record review, with multiple staff members expressing that the nurse's actions did not meet expectations. The physician also stated that he would have wanted to be notified and would have given orders for the resident to be sent to the hospital. The incident was identified as a deficiency and Immediate Jeopardy, as the nurse did not act in accordance with facility policy or professional standards.