Failure to Notify Physician of Significant Change in Resident Condition
Penalty
Summary
Fairview Nursing and Rehabilitation Center was found to be noncompliant with federal and state requirements regarding timely notification of significant changes in a resident's condition. The facility's policy requires nursing staff to notify the attending physician or physician on call when there is a significant change in a resident's physical, emotional, or mental condition. In the case reviewed, a resident with severe cognitive impairment, Alzheimer's disease, depression, bradycardia, altered mental status, and somnolence was readmitted to the facility following a hospitalization. Upon readmission, the resident was alert and able to communicate simple needs. On a subsequent day, the resident was observed by an LPN to be lethargic with minimal verbal response during a medication pass. As a result, several physician-ordered medications were omitted for that shift. The LPN attempted to contact the physician but did not receive a response and reported feeling uncomfortable administering medications due to the resident's status. According to facility policy, the next step would have been to inform the nursing supervisor if the physician could not be reached, but the RN supervisor could not recall being notified of the situation. The physician was not contacted until several hours later, after the resident's family requested hospital transfer due to the resident's increased lethargy. The physician then gave orders for hospital transfer, and the resident was subsequently admitted to the hospital with a diagnosis of renal failure. There was no documented evidence that the physician was notified of the significant change in the resident's condition or the missed medications in a timely manner, as required by both facility policy and federal regulations.
Plan Of Correction
F0580 1. MD notification of change and condition for Resident R1 occurred later in the day and resident sent to hospital. 2. The DON or designee audited all residents with a documented change in condition within the past 72 hours to ensure physician notification was completed and documented. Any missed notifications were completed immediately, and physician instructions were followed. 3. All licensed nursing staff will be re-educated on: Facility policy for "Notification of Change in Condition." 4. DON or designee will audit all change in condition events weekly for 4 weeks, then monthly for 1 month. Findings will be reported to QAPI committee.