Failure to Notify Physician of Complete Change of Condition and Inadequate Follow-Up
Penalty
Summary
The facility failed to ensure timely and complete communication with a resident's physician regarding a change of condition. A resident with diagnoses including ALS, diabetes type 2, and major depressive disorder experienced symptoms such as headache, cough, congestion, and expressed fear of choking and shortness of breath. The nurse on duty documented the resident's complaints and administered medications for headache and sore throat, but only notified the physician via text message about the cough and congestion, omitting the resident's fear of choking and shortness of breath. The nurse sent two text messages to the physician during the night shift, but did not receive a response during her shift and did not follow up by calling the physician, the DON, or the Medical Director as required by facility policy. The nurse endorsed the resident's care to the oncoming nurse without further escalation. The physician eventually responded to the text messages over eight hours later, but was not made aware of the full extent of the resident's symptoms, specifically the fear of choking and shortness of breath, which would have prompted different interventions. The resident remained anxious and symptomatic throughout the night, ultimately leading to the family calling 911 and the resident being transferred to a hospital, where he was diagnosed with pneumonia secondary to COVID-19 and hypoxia. Documentation was incomplete regarding the time, method of communication, and the content of the interaction with the physician, making it difficult to ascertain the sequence of events related to physician contact and response.