Failure to Notify Medical Director After Unresponsive Primary Physician During Resident Change of Condition
Penalty
Summary
Facility licensed staff failed to notify the Medical Director after being unable to reach the primary physician for a resident who experienced a significant change in condition. The resident, who had chronic respiratory failure, obstructive uropathy, anemia, and was dependent on staff for care, exhibited no significant urine output and later developed hematuria with reduced urinary output. Despite attempts to transfer the resident to a general acute care hospital, no beds were available, and the primary physician did not respond to calls from staff. The facility's policy required that if the primary physician and alternate could not be reached, the Medical Director should be contacted, but this step was not taken. The Director of Nursing confirmed that the Medical Director was not called during the period when the resident's condition was deteriorating and the primary physician was unresponsive. The Medical Director also stated that staff should have contacted him if the primary physician did not return their call, regardless of the time. As a result of the lack of physician response and failure to escalate to the Medical Director, staff ultimately called 911 to transport the resident to the hospital.