Failure to Notify Physician and PACE of Change in Condition
Penalty
Summary
The facility failed to notify the physician and the Program of All-Inclusive Care for the Elderly (PACE) of a significant change in condition for a resident who was admitted for respite care following a hospital stay. The resident had multiple complex diagnoses, including encephalopathy, seizure disorder, COPD, respiratory failure, diabetes, kidney failure, anxiety, and depression. Despite being cognitively intact, the resident was dependent on staff for most activities of daily living. The care plan required staff to observe for signs and symptoms of respiratory distress and to report abnormal findings to the physician as needed. On the day of the incident, the resident exhibited significant changes in condition, including lethargy, low oxygen saturation, low blood pressure, and decreased responsiveness. Multiple CNAs and LPNs observed and reported these changes, such as the need for sternal rubs to awaken the resident, oxygen saturation levels as low as 54%, and blood pressure readings below 90/56. Despite these findings, the nurse on duty administered medications, including a beta-blocker and a narcotic, without verifying blood pressure or notifying the physician of the abnormal vital signs and change in condition. The physician was not notified until the resident became unresponsive, at which point emergency services were called, and the resident was transferred to the hospital. Additionally, the facility did not communicate the change in condition or medication changes to the PACE organization, as required by the service authorization. Interviews with staff and the DON confirmed that the facility was unaware of the requirement to notify PACE of changes in care or condition. Documentation was incomplete, with missing vital signs and lack of timely change of condition forms. The failure to notify the physician and PACE of the resident's deteriorating condition and medication changes resulted in the resident being hospitalized and placed on life support.