Failure to Notify Physician and Monitor Resident Following Change in Condition
Penalty
Summary
The facility failed to ensure that a resident with a history of pneumonia, pleural effusion, heart failure, and systemic lupus erythematosus received appropriate assessment, monitoring, and physician notification in accordance with physician orders and facility policy. The resident experienced shortness of breath at rest, a low systolic blood pressure reading of 98/57 mmHg, and other symptoms such as productive cough, yellow sputum, congestion, and lethargy. Despite physician orders to notify the medical doctor if the systolic blood pressure fell below 110 mmHg and to monitor and report symptoms related to COVID-19, there was no evidence that the physician was notified when these conditions occurred. Interviews with staff confirmed that the resident's change in condition, including shortness of breath and low blood pressure, should have prompted immediate physician notification and further assessment. The LVN acknowledged that the physician should have been notified about the low blood pressure and that the resident should have been monitored for further decline. The RN and DON also stated that changes such as shortness of breath, low blood pressure, and lethargy are considered significant and require prompt reporting and monitoring. Documentation review showed that the resident was eventually tested for COVID-19, found positive, and subsequently transferred to an acute care hospital with diagnoses including acute hypercapnic respiratory failure and bilateral pleural effusion. However, the initial failure to notify the physician and monitor the resident as ordered represented a lapse in following both physician orders and facility policy, as well as county public health guidelines for COVID-19 management.