Failure to Ensure Timely Assessment, Physician Notification, and Documentation for Change in Condition and Fall Incident
Penalty
Summary
Facility staff failed to provide necessary care and services for two residents by not ensuring timely assessment, physician notification, or complete documentation during significant changes in condition and after an incident. For one resident with a history of hemiplegia, traumatic brain injury, diabetes, and memory deficits, staff did not perform a timely assessment or notify the physician when the resident complained of malaise and was subsequently transported to the hospital by his wife. Documentation was incomplete regarding the events leading up to the transfer, and the physician was not notified until several hours after the resident had already left the facility. The resident was later admitted to the hospital for suspected sepsis related to a complicated urinary tract infection, with symptoms of fever, chills, and malaise reported for several days prior to admission. For another resident with disseminated coccidioidomycosis and a thoracic spinal cord injury, staff did not notify the physician or conduct a thorough investigation after the resident experienced a fall. The clinical record and progress notes showed no evidence of physician notification following the fall, and the responsible nurse confirmed that neither the physician was notified nor the incident endorsed to the next shift. The interdisciplinary team note regarding the fall was created 11 days after the incident, and the investigation was incomplete, as not all involved staff were interviewed and there were discrepancies in the documentation of the circumstances surrounding the fall. Facility policies required prompt assessment, physician notification, and thorough documentation in the event of a change in condition or incident. However, in both cases, staff failed to follow these protocols, resulting in delayed notification and incomplete documentation. These failures were confirmed through interviews with staff and review of facility records and policies.