Failure to Notify Physician of Resident's Significant Improvement in Mobility
Penalty
Summary
The facility failed to notify the primary physician of a significant improvement in a resident's condition, specifically regarding the resident's ability to perform sit-to-stand transfers using both prosthetic legs. The resident, who had a history of bilateral lower extremity amputations and was admitted with diagnoses including Type 1 diabetes mellitus, was initially assessed by physical therapy (PT) as requiring moderate to maximal assistance for transfers and was not ambulating due to safety concerns. After discharge from PT, the resident was placed on a Restorative Nursing Aide (RNA) program for sit-to-stand transfers in the parallel bars, with the care plan instructing staff to monitor for changes and refer to nursing or rehabilitation with any change in condition. Over time, the resident demonstrated significant improvement, becoming able to perform sit-to-stand transfers with minimal or no assistance and expressing a strong desire to progress to walking. Despite this improvement, the change was not documented in the medical record, nor was it reported to the charge nurse or the primary physician as required by facility policy. Interviews with staff revealed that while the improvement was verbally communicated among RNA and PT staff, it was not formally reported or documented, and the required notification to the physician did not occur. As a result of this failure to communicate and document the resident's improvement, the resident continued with the RNA program and did not receive a reassessment or further PT services that could have supported greater independence with mobility, including walking. The facility's policy required notification of the physician and consultation when there was a significant change in a resident's physical condition, but this process was not followed in this case.