Failure to Notify Provider and Representative After Multiple Medical Incidents
Penalty
Summary
Facility staff failed to provide necessary care and services for a resident with severely impaired cognition and total dependence for ADLs, who experienced multiple medical incidents and a decline in health status. After a choking episode, staff did not notify the provider or the resident's representative, nor did they document the event in subsequent communications regarding the resident's new onset behaviors. The resident was placed on a trial pureed diet, but there was no evidence of timely provider notification or order changes following the choking event. Further, when the resident exhibited additional changes in condition—including vomiting, hypotension, tachycardia, and decreased oxygen saturation—there was again a lack of timely provider notification and no documented provider order for transport to the emergency room. The medical record also failed to show consistent provider notification regarding odorous urine and other changes in condition. These omissions delayed physician and representative input for testing, monitoring, and treatment, contributing to the resident's decline, hospitalization, and may have contributed to the subsequent death.