Failure to Promptly Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to promptly notify a resident's physician of a significant change in condition, as required by both regulation and facility policy. The resident, who had diagnoses including metabolic encephalopathy, cerebral atherosclerosis, type 2 diabetes mellitus, chronic kidney disease, and Alzheimer's disease, was documented as being severely cognitively impaired. Progress notes indicated that the resident exhibited significant agitation, increased difficulty with gait and balance, and was highly resistant to care. Over the course of two days, the resident's condition declined further, with increased confusion, inability to stand, and repeated episodes of legs giving out during transfers, which was a notable decline from her baseline status. Despite these documented changes, the registered nurse did not notify the resident's physician at the time the changes were observed, instead passing the information along in a shift report. The physician was not informed until after the resident was sent to the hospital and admitted with a urinary tract infection and altered mental status. Both the LPN and the facility administrator confirmed that the physician should have been notified of the change in condition, in accordance with facility policy and regulatory requirements.