Failure to Notify Physician of Significant Change in Condition
Penalty
Summary
The facility failed to notify a resident's physician about a significant change in the resident's physical condition. Specifically, a resident with a history of acute kidney failure and acute pancreatitis experienced a clinically significant episode of hypotension, with a recorded blood pressure of 73/48. Despite this event, there was no documented communication to or with the provider regarding the hypotensive episode, as confirmed by a review of the resident's progress notes and the electronic provider communication tool. The facility's policy requires nurses to notify the attending physician or practitioner when there is a significant change in a resident's physical, mental, or psychosocial status, including clinical complications. The care plan for the resident included monitoring for cardiac complications, but there was no evidence that the physician was informed of the low blood pressure event. The Director of Nursing stated that nurses are expected to assess and notify the doctor of any new or concerning symptoms, but this did not occur in this instance.