Failure to Notify Physician of Significant Change in Resident Condition
Penalty
Summary
The facility failed to immediately notify a resident's physician when there was a significant change in the resident's physical condition. Specifically, a resident with end stage renal disease, who was receiving dialysis, had a blood pressure reading of 80/42 prior to being transported to dialysis. The low blood pressure was documented by an LVN, who reported the finding to the ADON and the resident, but did not directly notify the physician or nurse practitioner as required by facility policy. The resident was subsequently transported to dialysis, where the dialysis nurse also noted hypotension and contacted the nephrologist, who ordered IV fluids. Despite these interventions, the resident's blood pressure remained low, and the resident was sent to the hospital for further evaluation and treatment. Interviews and record reviews revealed inconsistencies and lack of clarity regarding whether the physician or nurse practitioner was notified of the resident's low blood pressure prior to dialysis. The LVN involved stated she believed she had notified the nurse practitioner, but could not provide documentation or evidence of this communication. The nurse practitioner and other facility staff interviewed denied receiving notification about the resident's condition. Facility policy required prompt notification of the physician or nurse practitioner in the event of significant changes in a resident's condition, such as abnormal vital signs, but this protocol was not followed in this instance. The deficiency was identified as Immediate Jeopardy due to the failure to notify the physician of a significant change in the resident's condition, which resulted in delayed medical intervention. The facility's own policies and staff interviews confirmed that the expectation was for the physician or nurse practitioner to be notified of such changes, but this did not occur. The event was further substantiated by documentation from the dialysis center and hospital, as well as interviews with facility staff, all indicating that the required notification was not made in a timely manner.