Failure to Notify Physician and Representative of Change in Condition
Penalty
Summary
The facility failed to notify the physician and/or resident representative of significant changes in condition for two residents. For one resident who experienced a choking episode, the medical record did not show that the physician or the resident's representative were informed of the incident, a subsequent change in urine, or acute changes in the resident's status, including vomiting, abnormal lung sounds, hypotension, tachycardia, and low oxygen saturation. Although the family was eventually notified and the resident was transported to the emergency room, there was no documentation of timely notification to the physician or representative regarding these significant events. For another resident who sustained a skin tear to the upper left leg, the medical record did not indicate that the resident's representative was informed of the injury. Facility policy requires immediate notification of the physician and resident representative in the event of significant changes in physical status or the need to alter treatment. An administrative nurse confirmed that staff are expected to notify the appropriate parties in such situations, but this was not documented in the records reviewed.