Failure to Notify Physician and Responsible Party of Change in Condition
Penalty
Summary
A deficiency was identified when the facility failed to notify a physician and the resident's responsible party regarding a significant change in condition for one resident. The facility's policy required immediate notification of physicians and responsible parties in the event of any change in a resident's condition. However, documentation revealed that this protocol was not followed for a resident with a history of acute respiratory failure and multiple chronic conditions, including diabetes, congestive heart failure, and chronic obstructive pulmonary disease. On one occasion, the resident was found difficult to arouse, with abnormal vital signs including elevated blood pressure, low temperature, and a distended bladder with no urine output. Nursing staff intervened by providing warmth, administering BiPAP, and performing straight catheterization, but there was no documented evidence that the physician or the resident's son was notified of this change in condition. This lack of notification was confirmed through review of the clinical record and staff interviews. A subsequent similar event occurred several days later, during which the resident became pale, unresponsive, and had low oxygen saturation. On this occasion, the physician was notified and the resident was sent to the hospital, and a voicemail was left for the resident's son. The Director of Nursing confirmed that, in contrast to the later event, the required notifications were not made during the initial incident, which was not in accordance with facility policy.
Plan Of Correction
Resident 2's physician was notified of her change in condition on November 13, 2024. Resident 2's responsible party was not notified of the change in condition on November 13, 2024, as per her wishes. Immediate re-education was provided to the Registered Nurse by the Director of Nursing regarding the importance of ensuring a resident's physician and responsible family member or legal representative are notified as soon as possible of any changes in the resident's condition. Any resident who has a change in condition has the ability to be affected by this alleged deficient practice. A whole house audit of residents who recently had a change in condition was completed to ensure his/her physician and his/her responsible family member or legal representative were notified as soon as possible of the change in the resident's condition. Licensed nursing staff, including agency licensed nursing staff, were re-educated on the facility Notification of Changes Policy, including the importance of ensuring a resident's physician, responsible family member, or legal representative are notified as soon as possible of any changes in the resident's condition. The Director of Nursing/designee will randomly audit notifications of physicians and responsible family members/legal representatives of residents with changes in condition weekly times eight weeks and then monthly times four months, and then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement, and/or continuation of audits. Results of these audits will be reviewed in the Quality Assurance and Performance Improvement meetings times six months or until substantial compliance is noted.