Failure to Notify Physician and Resident Representative of Change in Condition
Penalty
Summary
Facility staff failed to promptly notify the resident representative when a resident experienced vomiting and was placed on contact precautions. Review of the clinical record showed that the resident was placed on contact isolation due to vomiting, but there was no documentation that the resident's representative was informed of this change in condition. Interviews with staff confirmed that notification should have occurred, and facility policy required prompt notification of changes in a resident's condition to the resident, physician, and representative. In another instance, staff did not notify the physician when a resident complained of burning and pain to the neck and repeatedly requested that the on-call physician be contacted for treatment. The resident, who was cognitively intact, reported that a chemotherapy cream had been mistakenly applied to the neck, resulting in a chemical burn. Despite the resident's insistence and repeated requests for hydrocortisone cream and for the on-call physician to be contacted, the nurse assessed the area, found no visible irritation, and decided not to call the on-call provider, instead placing the request in the nurse practitioner communication book for follow-up the next day. Progress notes documented the resident's ongoing complaints and the nurse's repeated assessments, which did not reveal visible signs of injury. Staff interviews indicated that the protocol was to call the on-call provider for medication needs or acute symptoms, and that it was the resident's right to have the provider contacted upon request. The facility's policy required prompt notification of changes in condition, but this was not followed in these cases.