Failure to Notify Physician of Resident's Change in Condition After Tracheostomy Tube Change
Penalty
Summary
The facility failed to notify a resident's physician when the resident experienced scant bleeding and significant pain at her tracheostomy stoma site following a tracheostomy tube change. The resident, who had a history of cerebral infarction, tracheotomy status, and acute respiratory failure, was documented as having severe cognitive impairment. Despite a physician's order specifying that the physician should be notified for severe pain, the licensed nurse administered Tylenol Extra Strength for pain rated at eight out of ten but did not contact the physician. Documentation in the Pain Assessment Flow Sheet and Medication Administration Record confirmed the administration of pain medication without physician notification. Interviews with facility staff, including the DON, respiratory therapist, and the nurse involved, revealed that the nurse did not notice the requirement to notify the physician as stated in the pain order. The facility's policy and procedure for change of condition, as well as the job description for licensed nurses, required prompt physician notification for changes in condition. The failure to notify the physician resulted in the physician being unaware of the resident's change in condition and unable to provide further instructions for care.