Failure to Notify Physician and Responsible Party of Change in Condition and Abnormal Lab Results
Penalty
Summary
Facility staff failed to promptly notify the attending physician and the resident's responsible party of a significant change in condition for a resident with cognitive impairment and multiple care needs. The resident, who had short and long-term memory problems, moderately impaired decision-making skills, and required extensive assistance with daily activities, was found to have a large, painful bruise on the forehead during a skin evaluation. Despite the resident being on anticoagulant medication, which increases the risk of complications from bruising, there was no documentation of communication with the physician or responsible party from the time the bruise was first identified until it was later noticed by the resident's daughter. Additionally, the facility failed to ensure that abnormal laboratory results for another resident with moderately impaired cognition and multiple chronic conditions were reviewed by the provider. The laboratory results included several abnormal findings, such as low red blood count, hemoglobin, hematocrit, and eGFR, as well as elevated glucose and hemoglobin A1c levels. There was no confirmation that these results were communicated to or reviewed by the provider as required by facility policy. Interviews with facility staff, including the Clinical Care Coordinator and Director of Nursing, confirmed that the required notifications to the physician and responsible party were not made in both cases. Facility policies clearly state the need for prompt notification of changes in condition, injuries, and abnormal laboratory results, but these procedures were not followed, resulting in deficiencies related to communication and timely notification.