Failure to Notify Physician of Significant Change in Condition and Critical Lab Results
Penalty
Summary
The facility failed to ensure timely and appropriate notification of a physician when a significant change in a resident's condition was identified. A resident with a history of atrial fibrillation and a recent surgical repair of a left femur fracture was admitted to the facility and subsequently experienced ongoing bleeding from the surgical incision site. Despite continued bleeding that required frequent dressing and linen changes, and a hemoglobin level that dropped to 7.7 g/dL, the physician was not notified as required by facility policy. Instead, the Certified Registered Nurse Practitioner (CRNP) was notified, and orders were obtained to hold the resident's anticoagulant (Eliquis) and obtain laboratory tests, but the physician was not directly informed of the abnormal lab results or the ongoing bleeding. Interviews with nursing staff revealed that the decision to notify the physician or CRNP was left to nursing judgment, and there was confusion regarding the policy for physician notification. The resident's medical record indicated that the CRNP was consulted and provided orders, but the attending physician and the orthopedic surgeon were not made aware of the critical lab values or the extent of the bleeding. The physician later stated that he would have wanted to be notified of the hemoglobin drop and would not have resumed the anticoagulant as was done. The lack of direct physician notification persisted even as the resident's condition deteriorated, with further drops in hemoglobin and eventual transfer to the hospital for symptomatic anemia and hypotension. The facility's failure to notify the physician of significant changes in the resident's condition, including ongoing surgical site bleeding and critically low hemoglobin levels, was determined to have caused, or was likely to cause, serious injury, harm, impairment, or death. This resulted in the citation of Immediate Jeopardy under F580 - Notify of Change (Injury/Decline/Room, Etc.), as the deficient practice directly affected the resident's safety and care.