Failure to Notify Physician of Responsible Party's Declined CT Scan
Penalty
Summary
The facility failed to notify a resident's physician after the resident's responsible party declined a recommended head CT scan following the discovery of discoloration on the resident's forehead. The resident, who had diagnoses including metabolic encephalopathy, depression, and generalized muscle weakness, was assessed as having severely impaired cognitive skills and lacked capacity to make decisions. After a certified nursing assistant reported the discoloration, the physician was initially notified and ordered monitoring and for the responsible party to be consulted regarding the CT scan. The responsible party was contacted and ultimately declined the CT scan. However, the licensed vocational nurse who received the responsible party's decision did not inform the physician of this outcome. Both the nurse and the director of nursing acknowledged that the physician should have been notified to allow for further recommendations or interventions. The facility's policy required prompt notification of the physician regarding changes in a resident's condition or status, but this was not followed, resulting in the physician being unaware of the responsible party's decision and no further interventions being ordered.