Failure to Notify Provider of Resident's Decline in Condition
Penalty
Summary
The facility failed to notify a resident's medical provider of a decline in condition, as required. The resident, who had a history of acute kidney failure, dementia, COPD, alcoholic cirrhosis, stroke, and UTI, was admitted with multiple complex diagnoses. Progress notes indicated that the resident had refused to eat for several days, and the medical doctor had instructed staff to consider emergency evaluation and hydration if the condition did not improve within 24 hours, with explicit instructions for nurses to contact providers with any concerns or changes. However, there were no progress notes documenting the resident's health status or any evaluations from 03/13/25 through 03/15/25, despite the resident's ongoing decline. On 03/16/25, the resident was sent to the emergency room for a decline in condition, ultimately requiring air medical transport for specialty care due to sepsis and UTI. Interviews with nursing staff and the DON confirmed that the provider should have been notified of the change in condition, but both providers interviewed stated they were not informed. The lack of documentation and failure to notify the provider of the resident's worsening symptoms directly led to the deficiency.