Failure to Provide Timely Physician Notification and Care for Changes in Condition
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for two residents. In the first case, a male resident with a history of osteomyelitis, peripheral vascular disease, and atherosclerotic heart disease experienced a significant change in condition, including blurry vision, increased heart rate, shortness of breath, and a drop in oxygen saturation below baseline. Despite these symptoms and unsuccessful interventions to improve his oxygenation, the physician was not notified at the onset of symptoms. The first attempt to contact the nurse practitioner was made over an hour later, and the resident was not transported to the hospital until three hours after the initial complaints, during which time his condition continued to deteriorate. Interviews with staff revealed delays in both notification and escalation of care, with confusion about when to contact emergency services in the absence of a physician's order. In the second case, a female resident with end-stage heart failure, atherosclerotic heart disease, chronic kidney disease, dementia, and hypertension developed open wounds on her lower legs. The wounds were first identified by a family member, who reported them to nursing staff. Despite the progression of the wounds and visible deterioration, there was no documentation of physician notification, no new treatment orders, and no interventions initiated by the facility. The resident was eventually admitted to the hospital with a diagnosis of cellulitis affecting both lower limbs. Record reviews confirmed the absence of timely physician notification and lack of appropriate wound care interventions. The facility's own policy required prompt notification of the attending physician for significant changes in a resident's condition, including the need to alter medical treatment or transfer to a hospital. However, in both cases, there was a failure to follow this policy, resulting in delayed medical intervention and escalation of care. Interviews with staff and review of documentation confirmed that these deficiencies were due to lapses in communication, assessment, and adherence to established protocols for managing changes in resident condition.