Failure to Notify Physician of Change in Condition
Penalty
Summary
The facility failed to notify the physician of a significant change in condition for one resident who developed edema, redness, and warmth in the left elbow. The resident had a history of chronic respiratory failure with hypoxia, contractures, and heart failure, and was dependent on staff for all activities. Initial assessments and skin evaluations upon admission and readmission did not document any edema or redness in the left elbow. On a subsequent assessment, the resident was observed to have a red, swollen, and warm left elbow. The treatment nurse and LVN both noted the change but were unsure if the physician had been notified, and there were no active treatment orders for the condition. Review of the resident's records, including physician orders and nursing progress notes, revealed no documentation that the physician had been informed about the new onset of edema or that any interventions had been initiated. Interviews with nursing staff and the Director of Nursing confirmed that the expectation was for licensed nurses to thoroughly assess residents and promptly report changes in condition to the physician. The facility's policy and procedure required immediate notification of the physician for changes such as swelling or discoloration. However, there was no evidence that this protocol was followed in the case of the resident's left elbow edema.