Failure to Notify Physician of Resident's Significant Decline
Penalty
Summary
The facility failed to notify the physician of a significant change in a resident's condition, despite multiple staff members observing a marked decline. The resident, who was admitted for rehabilitation following a stroke and was initially making progress in therapy, began to exhibit symptoms such as dizziness, lightheadedness, nausea, altered responsiveness, decreased communication, dry mouth, poor oral intake, reduced urine output, dark stools, and eventually tested positive for COVID. Therapy and nursing staff documented and discussed the resident's decline, but there was no timely communication with the physician regarding these changes. Throughout the resident's stay, therapy staff and nurse aides noted a regression in the resident's functional abilities, including a loss of ability to feed herself, ambulate, and communicate as she had previously. Multiple therapy notes and staff interviews indicated that the resident required increasing assistance, became less responsive, and was unable to participate in therapy or self-care. Despite these observations and documentation of the resident's deteriorating condition, the physician was not notified for several days. The only documented physician notification prior to the resident's hospital transfer was related to facial twitching, for which a medication was ordered, but subsequent and more severe changes were not communicated. The lack of physician notification persisted even as the resident's symptoms worsened, including after a positive COVID test and the onset of gastrointestinal symptoms such as dark stools and decreased intake. Staff interviews revealed a breakdown in communication between therapy, nursing, and management, with several staff members assuming others had notified the physician or were unaware of the resident's previous progress. Ultimately, the resident was transferred to the hospital in a critical state, where she was found to be septic due to COVID and had gastrointestinal bleeding, resulting in a critical hemoglobin level and heart injury.