Failure to Notify Physician of Change in Condition Leads to Resident Death
Penalty
Summary
A deficiency occurred when facility staff failed to notify a physician of a resident's significant change in condition, which included decreased urine output, refusal to eat, lethargy, and a worsening pressure ulcer. The resident, who had multiple comorbidities such as diabetes, peripheral vascular disease, and severe cognitive impairment, was totally dependent on staff for care and had a history of chronic wounds, including a stage 4 sacral pressure ulcer and a right heel arterial ulcer. Despite care plans and physician orders requiring prompt notification of changes in condition, staff did not communicate the resident's decline to the physician or responsible party in a timely manner. Documentation and interviews revealed that over several days, the resident exhibited clear signs of deterioration, including poor oral intake, minimal urine output, and a decline in wound status. Staff failed to consistently document meal and fluid intake, urine output, and wound care treatments, with some treatments not performed or recorded as required. Multiple staff members, including CNAs and nurses, observed or were informed of the resident's declining condition but did not escalate these findings to the physician, often citing uncertainty, lack of recall, or the expectation that the wound care provider would address the issue during scheduled rounds. The resident was ultimately sent to the emergency room only after a wound care nurse practitioner assessed the resident and found significant deterioration, including a necrotic, malodorous wound and signs of systemic infection. The resident was hospitalized with diagnoses of sepsis, dehydration, and failure to thrive, and died less than 24 hours after admission. Interviews with the resident's power of attorney and the medical director confirmed that neither had been notified of the resident's decline prior to the hospital transfer, despite facility policy requiring such notification for changes in condition.
Removal Plan
- A full house review of all residents with wounds was conducted to verify current wound status and ensure any noted decline was promptly communicated to the physician.
- A 72-hour audit of all residents for change in condition was conducted, including a review of Nurses Notes, Progress Notes, and Alert Charting.
- A full-house review of all residents was completed to verify current wound status and ensure any noted decline was promptly communicated to the physician. Any discrepancies identified were immediately corrected through direct physician notification and documentation updates.
- All licensed nursing staff received education on the requirements at F580, emphasizing timely physician and responsible party notifications for any change in condition, abnormal labs/vitals, new or worsening wounds, decreased urine output/fluid intake, and functional decline, and appropriate documentation of same.
- Certified Nursing Assistants (CNAs) were re-educated to immediately report any observed changes in condition to the charge nurse.
- The facility's Physician Notification and Change in Condition Policies were reviewed.
- Ongoing monitoring activities will be conducted: a. Conduct daily reviews of the Nursing 24 Hour Report to verify timely and accurate physician/responsible party notifications. b. Review a minimum of three random resident charts weekly to confirm compliance with F580 documentation standards. c. Immediately correct and reeducate any staff involved in identified discrepancies. d. Present audit findings and corrective actions during weekly Quality Assurance /Interdisciplinary Team Meetings. e. Provide ad hoc education and reinforcement as indicated.
- The Administrator will conduct the following ongoing monitoring activities: a. Validate and monitor audit outcomes weekly to ensure continued compliance. b. Conduct monthly Inservice education for all nursing staff on F580 notification standards and documentation requirements.