Failure to Notify Physician and Representative of Significant Change in Condition
Penalty
Summary
The facility failed to promptly notify the attending physician and the resident's representative of significant changes in the residents' physical status, as required by facility policy. In one case, a resident with a history of multiple medical conditions, including a femur fracture, multiple myeloma, and heart failure, developed new wounds on the left leg. The nurse observed redness, pitting edema, and multiple blisters, one of which was open. Although the findings were documented in the Nurse Practitioner communication book, the provider was not notified until several days later. There was no documentation of provider notification in the progress notes between the initial observation and the eventual evaluation, and the care plan for the new wounds was not created until much later. Interviews with staff confirmed that the nurse should have called the on-call provider immediately rather than relying on the communication book for such a significant change in condition. In another instance, a resident with diabetes, COPD, and atrial fibrillation developed conjunctivitis, and a new order for TobraDex eye ointment was initiated. While the change in condition and the new treatment were documented in the medical record, there was no documentation that the resident's representative was informed of either the change or the initiation of treatment. Staff interviews confirmed that the representative was not notified, and the Director of Nursing stated that notification and documentation should have occurred according to facility policy. The deficiencies were identified through record review and staff interviews, which revealed lapses in communication and documentation regarding significant changes in residents' conditions. The facility's own policy required prompt notification of both the attending physician and the resident's representative within 24 hours of a significant change, but this was not followed in the cases reviewed. The lack of timely notification and documentation was confirmed by multiple staff members, including nursing and administrative personnel.