Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
Skilled nursing staff failed to notify the physician of a significant change in condition for a resident who was admitted with post-polio syndrome and had previously been oriented to time and place. The resident experienced a sudden onset of hallucinations, including seeing snakes under the bed and believing bugs were crawling in the room, as well as an attempt to elope from the facility. Despite these notable changes in mentation and behavior, there was no documentation that the physician was notified during the initial episodes. The Director of Nursing confirmed that staff did not inform the physician about the resident's hallucinations, which are recognized as a potential sign of infection. The facility's clinical protocol required nurses to assess and report changes in cognitive and emotional status, but this was not followed. The physician was only notified after several days, at which point the resident was sent to the hospital for further evaluation and treatment.