Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify a physician of a significant change in condition for a resident with a complex medical history, including deep vein thrombosis, pulmonary embolism, stroke, diabetes, schizoaffective disorder, and cancer. The resident experienced an unresponsive episode observed by a nursing assistant, after which an LPN conducted an assessment. The assessment documented that the resident regained responsiveness within seconds, was able to answer questions, follow commands, and denied headache. However, there was no documentation that the provider was notified of this unresponsive episode, and the resident's care plan did not include a history of such episodes. Interviews with facility staff confirmed that the nurse in charge and the nurse practitioner were not informed of the incident, and both indicated that provider notification would have been expected according to facility procedures. The facility's policy required staff to notify the provider of significant changes in a resident's condition and to document this communication. The lack of provider notification and documentation following the unresponsive episode constituted a failure to follow established protocols for change of condition.