Failure to Notify Physician of Change in Condition and Hospital Transfer
Penalty
Summary
Facility staff failed to notify the medical provider of a significant change in condition for one resident, which resulted in the resident being transferred to a higher level of care. The resident had multiple complex diagnoses, including heart failure, atherosclerotic heart disease, chronic respiratory failure with hypoxia, atrial fibrillation, myocardial infarction, type 2 diabetes mellitus, cardiomyopathy, presence of a prosthetic heart valve, presence of a cardiac pacemaker, transient ischemic attack, and anxiety disorder. The resident was assessed as moderately impaired in cognition. On the evening in question, the resident experienced altered mental status, hypotension with blood pressure as low as 68/49, tachycardia, and tachypnea, leading to a transfer to the hospital and subsequent admission to the ICU for a stroke workup. A review of the clinical record and facility documentation revealed no evidence that the physician was notified of the resident's change in condition or of the transfer/discharge. The facility's policy requires nursing staff to notify the attending physician or physician on call in the event of a significant change in the resident's condition or when a transfer to a hospital is necessary. The director of nursing confirmed that there was no documentation of physician notification for this incident.