Failure to Notify Physician of Change in Resident Condition
Penalty
Summary
The facility failed to notify the physician of a change in a resident's condition as required by facility policy. A resident with diagnoses including severe protein calorie malnutrition, epilepsy, and dysarthria was observed by an LPN to have increased slurred speech, but the LPN did not notify the physician or document the observation, attributing the change to a previous respiratory illness. There was no documentation in the clinical record regarding slurred speech or its worsening during the relevant period. The facility's policy requires staff to notify the physician of significant changes in a resident's physical or mental condition, but this was not followed in this instance. Further review of the resident's record showed that a family member expressed concern about a dramatic negative change in the resident's vocal ability, prompting a nursing supervisor to assess the resident and arrange for hospital transfer. Hospital records indicated the resident presented with worsening dysarthria, confusion, bilateral lower extremity weakness, and was diagnosed with Dilantin toxicity. The failure to notify the physician in a timely manner about the resident's change in condition led to a delay in appropriate medical intervention.