Failure to Timely Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to ensure timely notification of a physician following a significant change in a resident's condition. The resident, who had a complex medical history including chronic iron deficiency anemia, diabetes, schizoaffective disorder, and a history of gastrointestinal (GI) bleeding, experienced multiple episodes of vomiting dark brown emesis. On one occasion, the resident vomited a large amount of dark emesis in the early morning hours, with vital signs showing low blood pressure and elevated heart rate. Despite these symptoms and the resident's request to go to the emergency room, the nurse practitioner (NP), director of nursing (DON), and executive director (ED) were not notified until several hours later. Documentation revealed that the resident had a known history of GI bleeding and had previously been hospitalized for similar symptoms. On the date in question, the resident began vomiting at 1:56 a.m., but the NP, DON, or ED were not notified until 8:28 a.m., more than six hours after the initial episode. During this time, the resident continued to vomit and exhibited an elevated heart rate. Only after the delayed notification was the NP contacted, who then ordered the resident to be sent to the emergency room for evaluation and treatment. Interviews with facility staff confirmed that the DON was not contacted at the time of the incident, and the nurse's notes did not reflect timely communication with the appropriate clinical leadership. The facility's policy required that all changes in resident condition be promptly communicated to the physician and responsible parties, but this protocol was not followed in this instance, resulting in a delay in medical intervention for the resident.