Failure to Promptly Notify Physician After Resident's Significant Change in Condition
Penalty
Summary
A deficiency occurred when facility staff failed to promptly notify a resident's physician following a significant change in the resident's condition. The resident, who had a history of osteomyelitis, peripheral vascular disease, and atherosclerotic heart disease, was admitted on antibiotic therapy. Over several days, the resident's oxygen saturation levels gradually declined. On the morning of the incident, the resident experienced blurry vision, shortness of breath, and a rapid heart rate, with oxygen saturation dropping to 76%. Despite these acute symptoms, the nurse initially attempted interventions such as elevating the head of the bed and administering supplemental oxygen, but the resident's condition did not return to baseline. The nurse increased oxygen delivery and eventually placed the resident on a non-rebreather mask, which temporarily improved oxygen saturation. However, the nurse did not immediately notify the physician or nurse practitioner upon recognizing the severity of the resident's symptoms. The first attempt to contact the nurse practitioner was made by text over an hour after the initial assessment, and there was a delay in response. During this period, the resident continued to deteriorate, and only after further desaturation and lack of improvement was the decision made to send the resident to the hospital. The nurse practitioner ordered the transfer after finally responding to the nurse's message. The resident was transported to the hospital several hours after the onset of symptoms. Interviews with staff and review of documentation confirmed that the physician was not promptly notified as required by facility policy when a significant change in condition occurred.