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F0580
D

Failure to Notify Physician of Change in Resident Condition

Eugene, Oregon Survey Completed on 08-11-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to notify a physician of a change in condition for a resident who was admitted with acute kidney disease and was cognitively intact, as indicated by a BIMS score of 14. On the evening in question, nursing notes documented that the resident developed draining blisters on the chest and reported sensations of burning and being stabbed with needles. The resident was subsequently sent to the emergency department. However, a review of the medical record confirmed that the physician was not notified of these changes in the resident's condition prior to the transfer. This lack of physician notification was acknowledged by the Corporate DNS, DON, and Regional nurse during interviews.

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