Failure to Timely Notify Physician of Change in Condition and Abnormal Imaging Results
Penalty
Summary
The facility failed to ensure timely physician notification and intervention for a resident who experienced a significant change in condition. The resident, who was dependent on gastrostomy tube (GT) feeding, was observed with a distended abdomen and had a care plan in place requiring monitoring and reporting of symptoms such as aspiration, fever, shortness of breath, tube dislodgement, infection, abdominal pain, distention, and tenderness. On the day of the incident, the resident exhibited chest congestion, cough, and abdominal distention, prompting a licensed nurse to notify the physician and obtain orders for STAT chest x-ray, KUB, and labs. Despite these orders, there was a significant delay in both the completion of the imaging and the communication of the results to the physician. The radiology reports, which indicated severe colonic distention and possible aspiration or developing consolidation, were transmitted to the facility late at night. However, documentation showed that the physician was not notified of these critical findings until more than seven hours after the reports were received. Interviews with nursing staff revealed that attempts to contact the physician were either not made in a timely manner or not documented, and there was a lack of follow-up as required by facility policy when the physician could not be reached. The delay in notifying the physician and obtaining further orders resulted in a late transfer of the resident to an acute care hospital for evaluation and treatment. The facility's policy required immediate notification of the physician and resident representatives in the event of a significant change in condition, but this protocol was not followed. The deficiency was confirmed through observation, interviews, medical record review, and review of facility policies and procedures.