Failure to Timely Notify Physician of Resident's Change in Condition
Penalty
Summary
A deficiency occurred when facility staff failed to notify a physician in a timely manner regarding a resident's significant change in condition. The resident, who had severe cognitive impairment, aphasia, schizophrenia, and was on multiple psychoactive and opioid medications, exhibited a gradual but clear decline over several days. Documentation showed the resident became increasingly lethargic, weak, and had difficulty maintaining an upright position, with poor oral intake and periods of apnea. Despite these changes, there was a delay in contacting the physician, with initial communication attempts not made until several days after the onset of symptoms. Progress notes indicated that the resident's condition began to deteriorate on a Friday, with staff noting lethargy, weakness, and decreased responsiveness. Over the weekend, the resident continued to decline, showing poor appetite, increased sleepiness, and difficulty with transfers and self-care. Staff communicated with the resident's Power of Attorney but did not reach out to the physician until the following Monday, at which point a fax was sent and follow-up calls were made. Orders for laboratory tests were not received until the next day, and the results revealed critical abnormalities, including severe hypernatremia and renal dysfunction, prompting hospital transfer. Interviews with staff confirmed that the resident's decline was observed by multiple caregivers, but action to notify the physician was delayed, particularly over the weekend when regular nursing staff were not present. The facility's policy required nursing staff to notify the physician of changes in a resident's condition, but this was not followed in a timely manner. The physician later stated that earlier notification could have led to earlier intervention. The deficiency was identified based on record review, staff interviews, and the facility's own policy documentation.