Failure to Notify Physician of Change in Condition and Medication Omission
Penalty
Summary
The facility failed to notify the physician of a significant change in condition for a resident with end stage renal disease, diabetes, hypertension, and a history of cerebral infarction. The resident, who was alert and oriented, experienced chest pain and was administered nitroglycerin as ordered. Following this, the resident developed hypotension, with blood pressure readings dropping to 80/40 and remaining low for several hours. Despite these abnormal findings and the resident presenting with increased lethargy, mild shortness of breath, and diminished lung sounds, there was no documentation that the physician or hemolytic center was notified of these changes. Nursing staff did not reassess vital signs in a timely manner, and the resident was sent to hemolytic treatment without physician notification. Upon return, the resident was found to be unstable and was sent to the emergency room, where they were admitted for hypoxic respiratory failure and exhibited stroke-like symptoms. In a separate incident, the facility failed to notify the physician when a prescribed medication was not available for administration to another resident. The resident, who was cognitively intact and required psychotropic medication for depression, did not receive Prozac as ordered on two consecutive days due to the medication not being delivered by the pharmacy. The responsible LPN did not notify the nursing supervisor, contact the pharmacy, or inform the physician about the missed doses. The MAR and nursing notes did not provide an explanation for the missed medication administration, and the issue was only addressed after the RN supervisor was informed by the LPN on the following day. Facility policy required immediate reporting of changes in condition to the unit manager or shift supervisor, assessment and documentation of the resident's status, and prompt notification of the physician for non-emergent changes. Additionally, policy required that discrepancies or omissions in medication delivery be reported to the pharmacy and charge nurse. In both cases, staff failed to follow these policies, resulting in a lack of timely physician notification for significant changes in condition and medication administration issues.