Failure to Notify Physician of Resident's Change in Condition and Treatment Refusal
Penalty
Summary
The facility failed to notify the physician of a significant change in condition and refusal of treatment for one resident. The resident, who had diagnoses including toxic encephalopathy and a urinary tract infection (UTI), exhibited behavioral changes and refused medications, blood sugar checks, and a physician-ordered urinalysis. Documentation shows that on June 16, the resident refused care and displayed aggressive behaviors, but there was no evidence that the physician was notified of these changes or the refusal to complete the urinalysis at that time. Physician notification did not occur until four days later, despite ongoing noncompliance and worsening behavior. Facility staff interviews confirmed that the refusal and behavioral changes should have been reported to the physician and documented in the medical record, in accordance with facility policy. The lack of timely physician notification and documentation was identified through observation, interview, and record review.