Failure to Provide Timely Care and Physician Notification for Change in Condition
Penalty
Summary
A resident with a history of respiratory failure and hypoxia experienced a significant change in condition, including an elevated pulse rate and decreased oxygen saturation. On multiple occasions, the resident was found with abnormal vital signs, such as a pulse ranging from 107 to 163 beats per minute and oxygen saturation levels as low as 65%. Despite these findings, there was no timely notification to the physician regarding the resident's deteriorating condition, and vital signs were not closely monitored at the recommended intervals. Documentation shows gaps in monitoring, with several hours passing between assessments, and a lack of consistent follow-up on the resident's status. The nursing staff did not notify the physician when the resident was found unresponsive with critically low oxygen levels and an elevated pulse. Subsequent assessments continued to show abnormal vital signs, but the physician was still not informed in a timely manner. The resident also refused oxygen therapy and transfer to the emergency room, but there was no evidence of persistent or immediate escalation to the physician or further intervention until much later. The facility's own policy required prompt assessment, physician notification, and close monitoring in the event of a change in condition, but these steps were not followed as documented in the records and confirmed by staff interviews. Interviews with facility leadership and nursing staff confirmed that the expected protocol was not followed. Staff acknowledged that the physician should have been notified, vital signs should have been monitored every 10–15 minutes, and 911 should have been called when the resident's oxygen saturation and pulse were critically abnormal. There was also no documentation that the physician came to evaluate the resident as promised, nor was there follow-up to ensure the physician's timely assessment. The failure to provide timely care and treatment according to orders and facility policy had the potential to delay necessary interventions and affect the resident's overall health condition.