Failure to Notify Physician and Responsible Parties of Changes in Condition
Penalty
Summary
Facility staff failed to notify physicians and/or responsible parties of significant changes in residents' conditions, as evidenced by multiple incidents. One resident was admitted in November 2024 and experienced several episodes of elevated heart rate prior to being transferred to the hospital, but there was no documentation that the physician was notified of these abnormal vital signs. The Medical Director confirmed that the physician was not informed of the elevated heart rates on the specified dates. Another resident, admitted with a history of stroke and diabetes, experienced multiple episodes of hypoglycemia, with blood sugar readings as low as 53 and 59 mg/dL, and eventually 36 mg/dL, which led to respiratory distress and transfer to the emergency room. There was no documentation that the physician or responsible party was notified of the low blood sugar incidents prior to the emergency event, a fact confirmed by the DON. Additional deficiencies included a resident with a missing front tooth, where there was no documentation that the responsible party was notified, and a significant weight loss in two residents without evidence that the dietician, physician, or responsible party were informed. Interviews with facility leadership confirmed the lack of notification and documentation regarding these changes in condition.