Failure to Notify Physician of Change in Resident Condition
Penalty
Summary
The facility failed to notify the physician of a significant change in a resident's condition, resulting in a deficiency related to prompt diagnosis and treatment. A resident admitted for short-term rehabilitation with a history of orthopedic aftercare, a femur fracture, shortness of breath, and interstitial pulmonary disease, was documented by nursing staff to have pain, swelling, redness, and warmth in her surgical leg. On one occasion, the nurse noted these symptoms and administered pain medication but did not notify the physician or document any such notification, despite the facility's policy requiring physician notification for significant changes in condition. Previous assessments had shown no edema at admission, but subsequent notes indicated the development of generalized edema, pain, and warmth in the lower extremities. Although the physician was notified on an earlier date when similar symptoms were present, there was no documentation of physician notification when the symptoms recurred and worsened. The resident was later transferred to the hospital, where she was diagnosed with deep vein thrombosis (DVT) in the affected leg. The facility's policy required timely notification and documentation of such changes, which was not followed in this instance.