Failure to Notify Physician of Change in Resident's Oral Condition
Penalty
Summary
The facility failed to follow its change of condition policy by not immediately notifying the physician or nurse practitioner when a resident developed white patches in the mouth and on the tongue. The resident, who had chronic respiratory failure, a tracheostomy, and required assistance with oral hygiene, was observed by a surveyor to have yellow mucous and raised white/yellow patches in the mouth. The resident reported not receiving oral care for two weeks. The nurse present at the time confirmed the observation. Despite the visible oral changes, the nurse practitioner was not notified until two days after the initial observation, and the medical doctor was not informed until the following day. Both practitioners stated they would have expected to be notified of such changes and would have initiated treatment sooner. The facility's policy requires prompt notification of the physician or nurse practitioner in the event of a significant change in a resident's condition, which was not followed in this case.