Failure to Notify Physician and Responsible Party of Significant Changes and Test Results
Penalty
Summary
The facility failed to ensure timely notification of a physician regarding abnormal vital signs for one resident and did not notify the responsible party about diagnostic test results and a new skin impairment for another resident. For one resident with multiple diagnoses including heart disease, hypertension, and hypotension, therapy staff documented several episodes of low blood pressure and fainting during therapy sessions. Despite these significant changes in condition, there was no documentation that the physician or nurse practitioner was notified of the abnormal blood pressure readings until several days later, even though the therapy staff requested physician input regarding blood pressure parameters and medication regimen. For another resident with dementia, diabetes, and a gastrostomy, the facility failed to notify the responsible party of a diagnostic procedure to verify gastrostomy tube placement and did not communicate the results. Additionally, the responsible party was not informed about a new wound on the resident's leg, which was discovered during an observation with nursing staff. The nurse responsible for skin integrity was unaware of the wound prior to the observation, and there was no evidence that appropriate orders were obtained for the dressing applied to the wound.