Failure to Promptly Notify Physician of Resident's Change of Condition
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) failed to promptly notify the physician of a resident's change of condition (COC). The resident, who had chronic obstructive pulmonary disease (COPD) and systolic congestive heart failure, was admitted with severely impaired cognition and required maximal assistance with daily activities. On the morning in question, the resident was observed to be confused, less responsive, and experiencing shortness of breath with increased fatigue. The Certified Nursing Assistant (CNA) reported these symptoms to the LVN, who checked the resident's oxygen level and administered a routine breathing treatment and oxygen, but did not immediately notify the physician of the change in the resident's condition. Further observations throughout the day confirmed the resident continued to have fast, shallow breathing and remained on oxygen. Interviews with staff, including the CNA, Activities Assistant, Registered Nurse (RN), and Director of Nursing, confirmed that the resident's symptoms were not typical and constituted a significant change in condition that required immediate physician notification according to facility policy. The facility's policy and procedure also required prompt reporting of any change in condition to the physician to ensure proper treatment, which was not followed in this instance.