Failure to Notify Physician and Follow Orders After Change in Condition
Penalty
Summary
The facility failed to follow its policy for change of condition notification and physician order compliance when a resident experienced a significant decline after a fall resulting in a femur fracture and shoulder contusion. After returning from the hospital, the resident was discharged with instructions to monitor for symptoms such as vomiting, lethargy, and confusion, which would require immediate medical attention. Despite documentation of these symptoms, including vomiting, lethargy, sweating, increased blood pressure, and elevated blood sugar, the facility did not notify the physician of all these changes, nor did they send the resident to the hospital in a timely manner. The resident continued to decline, exhibiting decreased oral intake, increased lethargy, inability to take oral medications, and eventually became unresponsive before being sent to the hospital, where the resident expired shortly after arrival. Interviews with staff revealed a lack of awareness and communication regarding the resident's after-visit hospital summary and the specific symptoms that should have prompted immediate action. Several LPNs and the ADON indicated they were either unaware of the discharge instructions or did not review the 24-hour report thoroughly. The DON and Interim DON both stated that staff should have notified the physician and sent the resident out when the change in condition was observed, regardless of the physician's initial reluctance. The medical director also confirmed that staff should have reported the resident's dropping blood pressure, as it could not be managed in the facility. Additionally, the facility failed to ensure physician orders for wound care were followed for another resident with a venous ulcer. The treatment administration record showed multiple days where the ordered wound care was not completed or documented. This failure to provide necessary wound care as ordered contributed to the resident's wound worsening over time, as documented in the wound reports. Both deficiencies were identified during the survey, with the first resulting in an Immediate Jeopardy finding.