Failure to Notify Physician and Responsible Party of Resident's Significant Change in Condition
Penalty
Summary
A deficiency occurred when the facility failed to immediately notify a resident's physician and responsible party of a significant change in the resident's condition. The resident, an older male with a history of stroke, dementia, chronic pain, and nicotine dependence, experienced a notable decline over several days. Staff observed that he was no longer getting out of bed, was unable to feed himself, and complained of leg pain during personal care. Despite these changes, there was no timely documentation or notification to the nurse practitioner or responsible party regarding his altered status. Multiple staff interviews revealed that the resident's decline was apparent for several days, with increased lethargy, decreased participation in meals, and a cessation of his usual smoking routine. Some staff members noted the changes but did not consistently communicate them to the nursing team or document them in the medical record. The resident's responsible party was not informed of these changes and only became aware of the situation after visiting and finding the resident unresponsive and in bed, which was a significant deviation from his baseline behavior. The lack of prompt notification and documentation led to a delay in medical intervention. The resident was eventually transferred to the hospital, where he was diagnosed with possible aspiration pneumonia, a urinary tract infection, and a left femur fracture. The facility's policy required immediate notification of significant changes in a resident's condition to the physician and responsible party, but this protocol was not followed in this case, resulting in the identification of an Immediate Jeopardy situation.