Failure to Notify Physician of Change in Condition
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident who was reviewed for this issue. On the evening in question, the resident experienced a decline, including excessive sweating and an oxygen saturation level of 89 percent. Despite these changes, the nurse increased the resident's oxygen from 2 liters to 4 liters via nasal cannula without first notifying the physician, as required by facility policy. The nurse on duty was not aware that the provider had not been notified, and the nurse practitioner on call did not receive any communication regarding the resident's change in condition or subsequent transfer to the hospital. The resident involved had a complex medical history, including acute and chronic respiratory failure, chronic obstructive pulmonary disease, multiple cardiac conditions, end-stage renal disease, anemia, hemiplegia, and dependence on supplemental oxygen. The facility's clinical guidelines specified that any change in condition, particularly oxygen saturation below 90 percent, should be reported immediately to the attending physician or provider on call. However, this protocol was not followed, and the provider was not informed prior to the resident's transfer to the hospital.