Failure to Notify Responsible Party and Medical Director of Change in Condition
Penalty
Summary
The facility failed to notify the Responsible Party (RP) and the Medical Director of a resident's significant change in condition, specifically a new diagnosis of peripheral vascular disease (PVD) with absent pedal pulses in both feet. The resident, who was severely cognitively impaired and had multiple comorbidities including diabetes, dementia, contractures, malnutrition, and hemiplegia, was seen by a podiatrist who documented the new diagnosis and associated symptoms. However, there was no documentation that the RP or the Medical Director was informed of this new diagnosis or the lack of pedal pulses, and the care plan was not updated to reflect these changes. Further review revealed that the resident developed a wound on the right smallest toe and was transferred to the hospital, where a diagnosis of high fever, severe sepsis, and possible osteomyelitis was made. The RP reported only being informed of the hospital transfer due to a fever and wound, but not of the underlying PVD diagnosis or the absence of pedal pulses. The RP also stated that during a care conference prior to the hospital transfer, there was no mention of wounds or PVD. Interviews with facility staff, including the Social Service Coordinator and DON, confirmed that they were unaware of the new diagnosis and had not reviewed the relevant podiatry consultation note. The Medical Director was not notified of the resident's new diagnosis, lack of pedal pulses, or the hospital transfer until well after the events occurred. The DON was unable to specify who was responsible for reviewing consultations and informing the Medical Director of changes in a resident's condition. The facility's process for reviewing and communicating new diagnoses and significant changes in condition was not followed, resulting in a lack of timely notification to both the RP and the Medical Director.