Failure to Notify Physician and Provide Timely Medical Care Results in Resident Harm
Penalty
Summary
A significant deficiency occurred when facility staff failed to notify the physician and seek medical treatment for a resident who experienced a marked decline in condition over a two-week period. Despite clear signs of deterioration, including decreased oral intake, weight loss, increased weakness, and changes in behavior, staff did not document or communicate these changes to the resident's physician or dietitian. The facility's own policies required prompt recognition and reporting of acute changes in condition, but these were not followed. Multiple staff interviews confirmed that although the resident's decline was observed and discussed among staff and with family, no physician notification or medical intervention was initiated during this period. The resident, who had a history of multiple chronic conditions including diabetes, malnutrition, chronic kidney disease, and obstructive uropathy with an indwelling urinary catheter, was not properly monitored for fluid intake, weight, or catheter care. Documentation revealed missed weekly weights, inconsistent meal consumption records, and a lack of monitoring of urinary output. The care plan was not updated to address the resident's rapid weight loss, decreased intake, or increased risk for infection and contractures until just before the resident was sent to the hospital. Staff failed to change the resident's urinary catheter as ordered, and there was no evidence of physician notification regarding the resident's significant decline or catheter-related issues. When the resident was finally sent to the hospital, he was found to be in critical condition, suffering from severe dehydration, acute encephalopathy, hypernatremia, bladder obstruction, lactic acidosis, complicated urinary tract infection, sepsis, metabolic acidosis, contractures, and bacterial pneumonia. Hospital staff documented evidence of poor hygiene, inadequate oral and catheter care, and severe malnutrition. The admitting hospital physician and nurse both noted that the resident's condition indicated prolonged neglect, and the facility's failure to provide necessary medical care and monitoring resulted in the resident's admission to the ICU for treatment of multiple life-threatening conditions.