Failure to Notify Physician of Significant Change in Resident Condition
Penalty
Summary
The facility failed to notify the physician when a resident developed bluish discoloration to the left foot, as documented in multiple progress notes over several days. Despite repeated observations of the discoloration and edema by various LVNs, there was no evidence that the physician was informed until the resident's daughter requested hospital evaluation. The facility's own policy required physician notification for significant changes in a resident's condition, such as clinical complications or deterioration in health, but this was not followed. As a result, the resident's nondisplaced fracture of the left great toe went unrecognized by the facility until after the delayed notification and subsequent hospital evaluation. Interviews with nursing staff confirmed that the discoloration was observed and documented, but the physician was not notified in a timely manner. The Assistant Director of Nursing also acknowledged the lack of timely physician notification, consistent with the facility's policy.