Failure to Notify Physician of Significant Change in Condition Resulting in Resident Harm
Penalty
Summary
The facility failed to immediately inform and consult with a resident's physician regarding significant changes in the resident's condition, specifically related to the management of an ileostomy. Nursing staff experienced ongoing difficulties maintaining the integrity of the resident's ileostomy system, resulting in frequent leakage, skin breakdown, and an inability to keep the wafer and bag securely attached. Despite repeated unsuccessful attempts to manage the situation using various interventions such as ostomy paste, skin prep, and powder, the severity of the resident's condition and the lack of improvement were not promptly communicated to the nurse practitioner or physician. Documentation and interviews revealed that the staff did not obtain new physician orders in response to the resident's deteriorating skin condition and persistent issues with the ostomy system. The resident, who had a complex medical history including Crohn's disease, severe protein-calorie malnutrition, and a recent ileostomy creation, experienced a rapid decline. The resident suffered from nausea, vomiting, abdominal pain, and bowel movements from the rectum despite the presence of an ileostomy. Staff and family interviews indicated that the resident was left in soiled conditions for extended periods, and there was a lack of timely and effective communication with the medical provider regarding the resident's worsening symptoms and the inability to manage the ostomy care. The resident was eventually transferred to the hospital, where he was diagnosed with sepsis and acute kidney injury, conditions attributed in part to the inadequate management and delayed medical intervention at the facility. Observations and interviews with staff, family members, and the resident himself confirmed that the facility's failure to notify and consult with the physician about the severity and persistence of the resident's condition led to a delay in appropriate medical treatment. The resident was found covered in vomit and feces at the time of transfer, and staff admitted to being unprepared and inadequately trained to manage the resident's complex care needs. The deficiency was identified as Immediate Jeopardy, as the lack of timely physician notification and intervention resulted in a significant decline in the resident's health and required hospitalization.