Failure to Notify Physician and Resident Representatives of Significant Changes
Penalty
Summary
The facility failed to notify physicians and/or resident representatives as required in several situations involving three residents. In one case, a resident who was admitted with multiple diagnoses, including acute embolism, alcohol abuse, and pain, left the facility against medical advice (AMA). The clinical record did not contain a physician’s order for the AMA discharge, nor was there documentation that the physician was notified when the resident left. The nurse’s note also lacked documentation of the resident’s departure and the required notifications, despite facility policy mandating immediate physician notification and documentation in such cases. Another resident, with a history of traumatic brain injury and diabetes, experienced both hypoglycemic and hyperglycemic episodes. The facility failed to notify the resident’s representative of a hypoglycemic event that required intervention, and there was no documentation that the physician was notified of a subsequent blood sugar reading above 400. Interviews confirmed that the advanced practice registered nurse (APRN) was not notified of the elevated blood sugar, and the LPN involved could not recall or document the necessary notifications or follow-up actions. Facility policy required prompt notification and documentation of abnormal blood sugar levels and changes in condition, which was not followed. A third resident, with a history of stroke and hemiplegia, was found by a dental provider to have moderate inflammation and a possible abscess of a tooth root. The clinical record did not show that the physician was notified of this finding, and the nurse who received the dental consultation did not communicate the change in condition as required. Interviews with dental and medical staff confirmed that the physician was not made aware of the dental issue, despite facility policy requiring notification of providers and families for any change in a resident’s baseline condition.