Failure to Notify Physician of Resident's Significant Change in Condition
Penalty
Summary
A deficiency occurred when facility staff failed to immediately notify a resident's physician of a significant change in the resident's condition. The resident, an older adult with a history of coronary artery disease, heart failure, hypertension, diabetes mellitus, and other chronic conditions, exhibited declining vital signs over several days, including persistently low blood pressure, low oxygen saturation, and episodes of hypoglycemia. Despite these abnormal findings, there was no timely physician notification or appropriate intervention documented by the nursing staff. The resident was noted to be increasingly lethargic, sleeping more than usual, and experiencing confusion and weakness. Family members expressed concern about the resident's condition and reported difficulty reaching him by phone. Nursing documentation indicated that the resident's blood pressure readings were repeatedly below normal, and his blood sugar dropped to hypoglycemic levels. However, staff did not consistently document these changes as a change in condition, nor did they promptly notify the physician as required by facility policy. Interviews with staff revealed a lack of awareness regarding the resident's diabetic status and confusion about when to notify the physician for abnormal vital signs. Ultimately, the resident's condition deteriorated to the point of requiring emergency transfer to the hospital, where he was found to be in acute hypoxic and hypercapnic respiratory failure, septic shock, acute renal failure, and persistent hyperglycemia. The hospital records indicated that the resident was critically ill with vital organ impairment or failure. The failure to recognize and act upon the resident's significant change in condition, including not notifying the physician in a timely manner, directly contributed to the severity of the resident's health crisis.