Failure to Notify Provider and Respond to Family Requests Regarding Change in Condition
Penalty
Summary
The facility failed to ensure that a Nurse Practitioner (NP) or physician was contacted when the family of a resident with multiple complex medical conditions, including sepsis, acute respiratory failure, diabetes, dementia, and recent hospitalizations, repeatedly requested to speak with one of them. The resident, who had severely impaired cognition, was reported by her daughter to be crying, miserable, and not acting like herself. Despite the family's multiple requests throughout the day for NP or physician contact due to concerns about the resident's change in condition and history of sepsis, there was no documented evidence that the NP or physician was contacted in a timely manner. The agency nurse responded dismissively to the family's requests and attempted to deter them from seeking hospital evaluation, even as the family expressed fear of a recurring infection. It was only after the Assistant Director of Nursing (ADON) became involved later in the evening that the NP on call was contacted and an order was obtained to send the resident to the emergency room. Documentation and interviews confirmed that the family had made several requests to speak with a provider and to have the resident evaluated, but these requests were not acted upon promptly. The deficiency was identified through record review and interviews, which revealed a lack of appropriate response to the family's concerns and failure to follow through with provider notification as required.