Failure to Notify Physician and Provide Standard Care for Changes in Condition
Penalty
Summary
The facility failed to provide necessary care and services in accordance with professional standards of practice and resident care plans for two residents. For one resident with a gastrostomy tube (G-Tube), the nurse observed a leak around the tube and improvised a repair using rubber bands and masking tape instead of medical-grade equipment. The nurse did not notify the on-call provider or document the incident at the time, resulting in the resident being off tube feeds for several hours. The makeshift repair led to soiling and discoloration at the G-Tube site, with stagnate content present, increasing the risk for infection. Facility policy and adopted clinical procedures required immediate provider notification and proper documentation for such complications, which was not followed. Another resident with a history of heart failure, coronary angioplasty, and atrial fibrillation experienced a significant decline in condition, including acute hypotension, refusal of medications, food, and fluids, and altered mental status. The nurse documented the low blood pressure and change in mentation but did not notify the physician or document any provider notification. The resident's care plan specifically required monitoring for changes in cognitive status and prompt physician notification for observed changes or side effects of medication, including hypotension. Facility policy also mandated immediate physician notification and documentation for significant changes in condition or refusal of treatment, which was not done in this case. These failures to escalate care, notify the physician, and document interventions as required by facility policy and professional standards resulted in the residents not receiving timely and appropriate treatment and care. The deficiencies were identified through record review and staff interviews, with evidence showing that the required actions were not taken at the time of the incidents.