Failure to Notify Provider of Resident's Change in Condition
Penalty
Summary
Facility staff failed to timely notify a resident's physician or nurse practitioner of a significant change in condition. Specifically, a resident with multiple diagnoses, including generalized weakness, peripheral artery disease, COPD, slurred speech, history of falls, and hypertension, was not given their prescribed amlodipine due to low blood pressure, as documented in the medical record. Despite this change in condition and the withholding of medication, the nurse practitioner was not informed while present in the building that morning. The nurse practitioner stated that she was only notified at lunchtime when the resident became unarousable, and not at the time the low blood pressure was first identified and the medication was held. The Director of Nursing confirmed that the nurse practitioner should have been notified about the low blood pressure and the decision to withhold the medication. This lack of timely communication regarding the resident's change in condition constituted the deficiency identified during the complaint survey.