Failure to Notify Physician and Hospice of Change in Condition
Penalty
Summary
A deficiency occurred when facility staff failed to immediately notify the physician and hospice team of a significant change in a resident's condition, specifically the presence of blood in the resident's indwelling Foley catheter. Despite multiple staff members, including CNAs and LVNs, being aware of the blood in the catheter and the resident's discomfort and pain, there was no documentation or evidence that the physician, hospice nurse, or the resident's family were promptly informed of this change. The issue was reported by the resident's family, who observed blood in the catheter and communicated this to nursing staff, but were told that hospice would be notified later due to weekend staffing. The resident in question had a complex medical history, including Parkinson's disease, acute kidney failure, obstructive and reflux uropathy, benign prostatic hyperplasia, and a history of urinary tract infections. The care plan required staff to monitor for signs and symptoms of urinary tract infection and to notify the charge nurse and physician for further assessment. Despite these directives, staff did not follow the notification protocol when the resident exhibited significant changes, such as blood in the catheter, low urine output, and increased pain. Interviews with staff revealed that the change in condition was passed on during shift reports but not escalated to the physician or hospice as required by facility policy. As a result of the lack of timely notification and intervention, the resident was eventually sent to the emergency room, where he was diagnosed with sepsis, acute urinary retention, complicated urinary tract infection, and dehydration. The resident was admitted to inpatient hospice care at the hospital and subsequently died. The facility's failure to notify the appropriate parties in a timely manner was identified as an Immediate Jeopardy situation by surveyors.