Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to immediately notify a resident's physician when there was a significant change in the resident's physical status. The resident, an older female with acute respiratory failure, chronic diastolic heart failure, end stage renal disease, and dependence on renal dialysis, experienced an episode of shortness of breath while being transported to a scheduled dialysis appointment. As a result, she missed her dialysis session. Documentation showed that the resident was on continuous oxygen therapy and had orders to maintain oxygen saturation above 92%. Review of the resident's medical record revealed no evidence that a Change in Condition Assessment was completed following the episode of shortness of breath, nor was there documentation that the physician was notified at the time of the event. A late entry was made two days later, but both the physician and nurse practitioner confirmed during interviews that they were not made aware of the episode when it occurred. The nurse practitioner and physician both stated that shortness of breath in this resident, given her comorbidities, would be considered a change in condition that warranted notification. Interviews with facility staff indicated that the ADON instructed the LVN to notify the physician and complete a Change in Condition Assessment, but the LVN only left a voice message for the physician and did not document this action or complete the assessment. The LVN cited the timing of the shift change as a reason for not completing the documentation, assuming the oncoming nurse would do so. The facility's policy required immediate notification and documentation of significant changes in status, which was not followed in this instance.