Failure to Notify Physician of Resident Change in Condition and Transfer
Penalty
Summary
The facility failed to notify the physician in a timely manner for two of three sampled residents during significant changes in their condition. For one resident with chronic obstructive pulmonary disease and severe cognitive impairment, the resident called 911 due to difficulty breathing and was transferred to a general acute care hospital without the physician being notified of the change in condition or the transfer. The licensed vocational nurse confirmed that the physician was not informed as required. For another resident with epilepsy, schizophrenia, and bipolar disorder, documentation showed new skin redness and later episodes of undressing, refusal of care, and increased confusion. In both instances, the facility's records indicated that the physician was either not clearly informed or there was no follow-up or escalation to the medical director when a response was not received. The facility's policy requires immediate notification of the physician and responsible parties in the event of significant changes in a resident's condition, but this was not followed in these cases.