Failure to Notify Physician and Representative of Significant Change in Condition
Penalty
Summary
The facility failed to notify the attending physician and the resident's representative when a significant change in condition occurred for one resident. The resident, who had a history of prostate cancer, chronic kidney disease stage 3, and acute respiratory failure with hypoxia, was admitted and later readmitted to the facility. On a specific date, the resident was noted to have hematuria (blood in the urine), which constituted a significant change in condition as defined by the facility's policy. Review of the resident's records showed that a urinalysis and urine culture were ordered and sent to the laboratory due to the presence of blood in the urine and lower abdominal pain. Laboratory results indicated elevated white and red blood cells and a positive urine culture for proteus mirabilis, a common cause of urinary tract infections. Although the urinalysis result was reported to the physician, there was no documentation that a Change of Condition (COC) note was created at the time the hematuria was first observed, nor was there evidence that the resident's representative was notified as required by facility policy. Interviews with the Quality Assurance Nurse and the Director of Nursing confirmed that the facility's protocol required immediate creation of a COC note, notification of the physician, and notification of the resident's representative when a significant change in condition was identified. Both staff members acknowledged that these steps were not documented or verifiable for the date when the hematuria was first observed, indicating a failure to follow established procedures for timely notification.