Failure to Notify Physician of Significant Change in Resident Condition
Penalty
Summary
The facility failed to directly notify the primary physician of a significant change in condition for a resident who was under hospice care and had multiple diagnoses, including dementia, diabetes mellitus, epilepsy, and joint stiffness. On 2/14/2025, the resident experienced decreased mobility, increased pain, and swelling in the right arm, with an inability to spread the fingers. The facility's records show that the hospice coordinator was notified, and a hospice nurse was scheduled to assess the resident, but there was no documentation that the resident's primary physician was informed of the change in condition. Subsequent progress notes indicated ongoing pain and swelling in the resident's right arm, with follow-up communications made only with the hospice company. The hospice nurse did not provide new orders, and the primary physician was not contacted directly by the facility staff. Interviews with facility staff confirmed that the standard practice is to notify the physician in the event of a change in condition, but in this case, only the hospice provider was notified. There was no documentation of physician notification, and the director of nursing acknowledged that the physician was not properly notified. Observations and interviews with staff and family members confirmed the resident continued to experience pain and limited use of the right arm. The facility's policy required timely notification of the resident, family, and physician in the event of a significant change in condition, but this was not followed. The deficiency was identified through review of records, staff interviews, and direct observation of the resident's condition.