Failure to Notify Physician of Change in Resident's Condition
Penalty
Summary
The facility failed to provide necessary care and services by not notifying a resident's physician when there was a significant change in the resident's condition, specifically a change in urine color from yellow to dark amber. According to the facility's policy and procedure on Notification of Changes, staff are required to inform the physician and the resident or their representative when there is a change that requires such notification. Review of the resident's closed medical record showed documentation by an LVN of the change in urine color, but there was no evidence that the physician was notified of this change. Interviews with the LVN, the physician assistant (PA), and the Director of Nursing (DON) confirmed that the physician was not notified about the resident's dark amber urine. The LVN acknowledged observing and documenting the change but did not report it to the physician, and both the PA and DON verified that there was no documentation of physician notification in the medical record. The failure to notify the physician occurred despite the facility's policy requiring such action when a resident experiences a change in condition.