Failure to Provide Timely Physician Notification and Care for Change in Condition
Penalty
Summary
A deficiency occurred when a resident with a history of paraplegia, urinary tract infection, iron deficiency anemia, acute pyelonephritis, and neuromuscular dysfunction of the bladder did not receive appropriate care and treatment in response to an evolving change in condition. Over a four-day period, the resident experienced multiple documented symptoms including elevated temperature (up to 103°F), elevated heart rate (up to 148), abdominal pain, nausea, vomiting, and malaise. Despite these symptoms, there was no documented evidence that the attending physician was promptly notified or that new orders were obtained to address the resident's deteriorating condition. Nursing staff made initial calls to the physician's service but did not consistently follow up or document physician responses, and there was no evidence of lab work, urinalysis, or urine cultures being ordered prior to the resident's transfer to the hospital. The resident's care plan included interventions such as monitoring for infection, reporting findings to the physician, and managing pain, but these interventions were not fully implemented. The resident continued to report pain, which increased in severity, and was only administered Tylenol with unresolved results. Requests for stronger pain medication and a pain management consult were not documented as being communicated to the physician, and there was no evidence that the resident's worsening symptoms were escalated appropriately. Multiple staff interviews confirmed that follow-up with the physician was lacking, and documentation of actions taken was incomplete or absent. Ultimately, the resident was not transferred to the hospital until three days after the onset of symptoms, at which point he was diagnosed with severe sepsis, scrotal abscess, and multiple infections. Interviews with staff and the resident confirmed that symptoms were ongoing and that the resident's requests and complaints were not adequately addressed. The Director of Nursing acknowledged that nursing staff should have promptly contacted the physician, ensured a response, and documented all actions taken, but this did not occur during the incident in question.