Failure to Notify Physician of Change in Resident Condition
Penalty
Summary
The facility failed to notify a resident's primary physician following a significant change of condition. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, experienced a seizure, an irregularly high heart rate (147-152 bpm), and low oxygen saturation (85%). Nursing staff provided oxygen and implemented seizure precautions, and a message was left with the physician's answering service. However, there was no documentation that the physician returned the call or that new orders were received. Interviews with staff confirmed that the physician was not reached directly and that no further action was taken to obtain medical orders or escalate the situation, such as contacting the medical director, as required by facility policy. The nurse practitioner stated that the resident should have been sent to the hospital for evaluation, and the DON confirmed that the protocol was to contact the medical director if the primary physician did not respond. The facility's policy required prompt physician response and further escalation if no timely response was received, which was not followed in this case.