Failure to Timely Notify Physician and Emergency Contact of Change in Condition
Penalty
Summary
The facility failed to notify a resident's physician and emergency contact in a timely manner following a significant change in the resident's condition. According to facility policy, nursing staff are required to inform the primary care physician and responsible party when there is a notable decline in a resident's clinical status. In this case, a resident with a history of NSTEMI myocardial infarction, type II diabetes, and muscle weakness exhibited slurred speech and appeared 'a little off' during the night. Despite this change, there was no timely notification to the physician or emergency contact, nor was this action documented in the clinical record at the time of the incident. The Director of Nursing and Nursing Home Administrator later confirmed that proper notification and documentation should have occurred.