Failure to Notify Provider of Resident's Acute Condition Change
Penalty
Summary
Nursing staff failed to notify the provider of a significant change in condition for a resident who had recently been readmitted with new diagnoses of aspiration pneumonia and pericardial effusion. The resident, who had a complex cardiac history including atrial fibrillation, cardiac pacemaker, hypertension, coronary artery disease, and unstable angina, reported feeling unwell, appeared extremely pale, and was more lethargic than usual. A nurse observed these changes, noted a bluish tint to the resident's lips, and applied oxygen at 3 liters via nasal cannula, which was a new intervention for this resident. Despite these acute changes and the initiation of oxygen therapy, the nurse did not notify the provider or obtain new orders, and there was no documentation of provider notification in the medical record. Interviews with facility staff, including the nurse practitioner and the director of nursing, confirmed that the provider was not informed of the resident's decline or the need for oxygen. The facility's policy required nursing staff to notify the attending physician or on-call physician when there is a significant change in a resident's condition, such as decreased food intake or changes in skin color or condition. In this case, the required notification and documentation did not occur, constituting a failure to follow established protocols for managing acute changes in resident condition.