Failure to Notify Physician and Document Significant Change in Condition
Penalty
Summary
The facility failed to notify a physician after a significant change in condition for a resident who exhibited abnormal laboratory results. The resident, who had diagnoses including metabolic encephalopathy, hypertension, and dementia, was dependent on staff for activities of daily living and had moderate cognitive impairment. A urinalysis revealed several abnormal findings, including turbid urine, moderate blood, positive protein, large leukoesterase, elevated white blood cells, and moderate bacteria, all of which were flagged as abnormal. Despite receiving these abnormal lab results, the Registered Nurse Supervisor confirmed that there was no documented evidence that the physician or the resident's responsible party was notified. Additionally, there was no documentation of an SBAR (Situation, Background, Assessment, Recommendation) or progress notes indicating that the physician had been informed, even though the nurse had received the results. The Director of Nursing also confirmed that abnormal urinalysis results are considered a significant change in condition and require prompt notification of the physician and responsible party, as well as proper documentation, none of which occurred in this case. A review of the facility's policies and procedures indicated that staff are required to promptly notify the attending physician and the resident's representative of any significant changes in the resident's condition, including abnormal lab results. The policies also require documentation of how, when, and to whom the information was provided. In this instance, the required notifications and documentation were not completed, resulting in a deficiency.