Failure to Notify Physician of Resident Change in Condition and Hospital Transfer
Penalty
Summary
A deficiency occurred when a nurse failed to notify a resident's physician of a significant change in the resident's physical status and subsequent transfer to the hospital. The resident, who was cognitively intact and his own responsible party, had a complex medical history including acute embolism, thrombosis, atrial fibrillation, chronic pulmonary edema, and peripheral vascular disease. On the day of the incident, the resident reported shortness of breath and leg pain, symptoms consistent with his history of deep vein thrombosis, and requested to be sent to the hospital. The nurse did not assess the resident or gather further information about his symptoms, nor did she notify the physician or other facility leadership about the resident's request or change in condition. The situation escalated when the resident became verbally aggressive after feeling his concerns were dismissed. The nurse left the area and called the police, expressing concern for her safety but did not communicate the resident's medical complaints or his request to go to the hospital to the police, physician, or other staff. When police arrived, they observed the resident's symptoms and contacted EMS, who transported the resident to the hospital for evaluation of possible blood clots and shortness of breath. The nurse did not participate in the transfer process or provide necessary documentation for the resident's hospital transfer. Interviews with facility staff, including the DON and other nurses, confirmed that the physician was not notified of the resident's change in condition or hospital transfer. The DON and the resident's physician both stated that they expected the nurse to assess the resident, notify the physician, and facilitate the transfer if needed. The facility's policy required prompt notification of the physician for changes in a resident's condition and prior to hospital transfer, which was not followed in this case.