Failure to Timely Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify a resident's physician in a timely manner following a significant change in the resident's condition. Documentation showed that the resident experienced multiple episodes of low blood pressure, with readings as low as 74/42, and other abnormal vital signs beginning at 5:00PM. Despite these changes, there was no evidence that the physician was notified until approximately 4 hours and 13 minutes later, at 9:13PM, when an electronic message was sent by an LPN to the physician. The physician responded at 9:34PM. The Director of Nursing confirmed that there was no documentation of earlier notification to the physician regarding the resident's condition. The delay in communication was verified through interviews and review of the medical record, and the concern was acknowledged by facility leadership during the survey process. The deficiency was identified for one resident reviewed for neglect during the survey.