Failure to Notify Physician and Representative of Significant Change in Condition
Penalty
Summary
The facility failed to immediately consult with a resident's physician and notify the resident representative when there was a significant change in the resident's condition or a need to alter treatment. Specifically, the facility did not notify the physician when the resident's vital signs were abnormal over several days, despite documentation and reports from staff and family that the resident was lethargic and fatigued. The resident was ultimately sent to the hospital after the family alerted a nurse to critically low blood pressure, where the resident was diagnosed with sepsis from a UTI. The resident involved was an elderly female with a history of multiple medical conditions, including fractures, hypertension, chronic pain syndrome, atrial fibrillation, repeated falls, and reduced mobility. Her care plan did not include a focus on urinary incontinence, risk for UTI, or hypertension. Medication administration records showed that antihypertensive medications were held multiple times due to low blood pressure, but there was no documentation that the physician was notified of these abnormal readings. Staff interviews revealed that the resident was observed to be lethargic and fatigued throughout the week, with these concerns reported by both staff and family, but not escalated to the physician. Interviews with facility staff, including the DON, nurses, and CNAs, indicated a lack of clarity and consistency regarding when to notify the physician of abnormal vital signs and changes in condition. The facility's policy required prompt notification of the physician and resident representative for significant changes, but this was not followed. The physician confirmed he was not notified of the abnormal vital signs prior to the resident's transfer to the hospital. The failure to notify the physician and the resident's representative of significant changes in condition was identified as a deficiency by surveyors.
Removal Plan
- Inform the Medical Director of the Immediate Jeopardy.
- In-service licensed staff on notifying physician of abnormal vital signs when accompanied by symptoms and standard disease related clinical interventions by the licensed nurse are not successful.
- Train staff on notifying the physician of abnormal vital signs when accompanied by symptoms and standard disease related clinical interventions by the licensed nurse are not successful, assessing a resident for change of condition, and notifying physician of change in conditions.
- Review all patients for documented low blood pressure. If a patient is noted to have blood pressures outside of the specified order parameters, notify the MD or NP. If neither are available, or in an emergent situation, contact emergency services (911).
- In-service ADON, Administrator, Medical Records, and Wound Care Nurse on notifying physician of change of condition and assessing the patient for change in condition and identifying a major decline or improvement in the resident's status.
- Initiate staff (LVN, RN, CNA) in-servicing on notifying of changes in condition and quality of care. Any staff who have not received in-servicing will not be permitted to work until in-servicing has been completed. In-servicing will be on-going for PRN, new staff, staff on leave, agency (if applicable).
- If a CNA obtains abnormal vital signs they will notify their charge nurse immediately. Charge nurse will then re-assess resident and re-take vital signs. The physician is to be notified of abnormal vital signs when accompanied by symptoms and standard disease related clinical interventions by the licensed nurse are not successful.
- Notify the physician of abnormal vital signs when accompanied by symptoms and standard disease related clinical interventions by the licensed nurse are not successful, based upon direction of the medical director.
- Define abnormal vital signs as: Systolic BP less than 90, Diastolic less than 50, Systolic greater than 180, Diastolic greater than 100, Heart rate less than 50, Heart rate greater than 130.
- ADON/DON/designee will review the exception report for low blood pressures with systolic blood pressures less than 90 and diastolic less than 50. Review will occur daily for 2 weeks, then 5 times weekly for 6 weeks, and then 3 times weekly for 4 weeks.