Failure to Timely Notify Physician of Change in Condition
Penalty
Summary
Facility staff failed to notify the physician in a timely manner regarding a resident's change in condition, specifically swelling and redness to the left knee observed on 3/6/24. The initial observation of the knee issue was made by a CNA and reported to the primary nurse, who assessed the resident but did not immediately document the findings or directly notify the physician. Instead, the information was placed in the physician communication book, which is used for non-urgent matters to be addressed during the physician's next visit. The physician did not see the resident until the following day, at which point an x-ray was ordered. The resident had a history of a fall on 2/25/24, after which no injuries were noted and the resident did not initially complain of pain. Over a week later, swelling and redness were observed in the left knee, but there was no immediate documentation or direct physician notification regarding this change in condition. The clinical record lacked evidence of timely documentation or communication to the physician about the new symptoms observed on 3/6/24. Interviews with facility staff confirmed that the nurse should have called the physician and documented the assessment and findings in the medical record, rather than relying on the communication book. The delay in direct physician notification and lack of timely documentation in the clinical record constituted the deficiency identified by surveyors.