Failure to Notify Provider of Significant Change in Resident Condition
Penalty
Summary
The facility failed to ensure timely notification of a medical provider following a significant change in condition for a resident with dementia and chronic obstructive pulmonary disease (COPD). The resident, who was alert and oriented with a history of stable oxygen saturation, experienced episodes of shortness of breath and a drop in oxygen saturation, which were managed with breathing treatments and supplemental oxygen. However, on one occasion, the resident exhibited a change in mental status, including confusion and hallucinations, along with a further decrease in oxygen saturation. Despite these significant changes, there was no documentation that the supervising nurse or the on-call provider was notified as required by facility policy. Interviews with facility staff confirmed that the LPN who observed the change in mental status did not notify the nursing supervisor, and the supervisor was unaware of the resident's altered condition. The DON and Medical Director both acknowledged that the change in mental status constituted a significant change in condition and that the supervisor and provider should have been contacted. Facility policy directs that every resident's change in condition must be reported to the physician, but this protocol was not followed in this instance.