Failure to Notify MD of Resident's Significant Condition Changes
Penalty
Summary
The facility failed to notify the Medical Director (MD) of significant changes in a resident's condition, specifically when the resident refused to eat, refused all medications, and exhibited aggressive behavior. The resident, who had diagnoses including dementia with behavioral disturbance and suicidal ideations, was observed over two consecutive days to be non-compliant with care and displaying concerning behaviors. Progress notes documented the resident lying in bed facing the wall, refusing food, medications, and a Covid booster, as well as acting aggressively by pretending to take medication and then discarding it. Despite these documented changes, the licensed nurse did not inform the MD, as confirmed during interviews. The Director of Nursing (DON) acknowledged that the nursing staff should have notified the MD about the resident's behavioral changes and refusals, as per facility policy. The MD also confirmed that he was not notified and would have wanted to be informed to consider further evaluation or interventions. Review of the facility's policy indicated that the nurse is required to notify the physician or nurse practitioner of significant changes in a resident's condition or when there is a need to alter medical treatment. The failure to notify the MD resulted in the MD being unable to assess the resident's health status and potentially delayed treatment.