Failure to Timely Notify Physician and Family of Change in Condition and Significant Weight Loss
Penalty
Summary
Facility staff failed to notify a resident's physician in a timely manner following a significant change in condition. One resident, admitted with heart failure, experienced a sudden drop in blood pressure. Nursing notes documented that the resident's blood pressure fell to 70/54 and continued to decline over several hours. Despite repeated attempts to page the provider, there was no response, and the physician was not notified promptly. The family was present and refused hospital transfer, but the facility did not escalate the situation to the Medical Director as expected when the primary physician could not be reached. In another case, a resident experienced a significant weight loss of 25.8 lbs (20%) over three weeks. The medical record did not show timely notification to the physician, dietician, or family when the weight loss was identified. The dietician did not assess the resident until 11 days after the weight loss was documented, and the resident was not evaluated in weekly risk meetings until 13 days later. Facility policy required prompt notification of significant changes in condition, but this was not followed in these instances.