Failure to Notify Physician of Change in Resident Condition
Penalty
Summary
A deficiency occurred when nursing staff failed to immediately notify a physician of a significant change in a resident's condition. The resident, who had a history of congestive heart failure and diabetes and was assessed as cognitively intact, presented with markedly abnormal vital signs, including a high fever, elevated pulse, and abnormal blood pressure. These abnormal findings were initially reported by a nursing assistant to the assigned nurse, who instructed a recheck of the vital signs. Despite the persistence of abnormal readings, there was no documentation or evidence that the physician was notified at that time. The breakdown in communication continued during the shift change, as the off-going nurse did not relay the abnormal findings to the oncoming nurse. The oncoming nurse only became aware of the resident's condition after a family member expressed concern, prompting a review of the resident's chart and subsequent notification to the on-call provider. Interviews with staff confirmed that the abnormal vital signs were not reported to the physician until approximately two hours after they were first identified, contrary to facility expectations for immediate notification of changes in resident status.