Failure to Notify Provider of Significant Change in Condition for Dialysis Resident
Penalty
Summary
The facility failed to provide timely notification to a provider regarding a significant change in condition for a resident who was receiving dialysis and had a history of hypotension. The resident's care plan directed staff to keep the medical doctor informed of changes, and physician orders required vital signs to be taken after dialysis on specific days. Blood pressure records showed multiple low readings, including a notably low value of 76/43, but there was no evidence that the physician or nurse practitioner was notified of this critical change. The nurse manager was unaware of the low reading and could not confirm if the provider had been informed. Further, the nurse practitioner confirmed that neither she nor the physician had been notified of the resident's low blood pressure, which she considered concerning and would have warranted immediate action. The nurse practitioner was also unaware that the resident had been sent to the emergency department from dialysis with an even lower blood pressure and was subsequently admitted to the intensive care unit. Facility policy required that changes in a resident's condition be reported to the attending physician, but this protocol was not followed in this instance.