Failure to Notify Providers of Significant Changes in Resident Condition
Penalty
Summary
Facility staff failed to notify providers of significant changes in condition for three residents, as required by facility policy and provider orders. For one resident with end-stage kidney disease and diabetes, staff did not notify the provider after the resident experienced a critically low blood sugar of 46 mg/dl, exhibited lethargy, low oxygen saturation, and expressed distress. Documentation was missing for blood sugar rechecks, oxygenation status, provider notification, and administration of glucose gel, despite clear orders to notify the provider in such events. Another resident with a history of stroke and hypertension experienced multiple episodes of extremely low blood pressure over several days while being treated for gastroenteritis. Although medication was held appropriately, there was no documentation of provider notification or assessment related to the abnormal blood pressure readings. Staff interviews confirmed that abnormal vital signs should have been reported to the provider, but this was not done or documented. A third resident with diabetes had several blood sugar readings above 300 mg/dl, as well as missing blood sugar measurements, without any documentation that the provider was notified as ordered. Progress notes did not explain the missing measurements or indicate that further instructions were sought from the provider for the management of elevated blood sugars. Clinical leadership acknowledged the lack of documentation and provider notification for these events.