Failure to Timely Notify Provider of Acute Change in Condition
Penalty
Summary
A deficiency occurred when the facility failed to provide timely notification to a resident's provider regarding an acute change in condition. The facility's policy requires immediate notification of the attending physician, resident representative, and supervisory staff when a resident experiences a significant change in condition, such as symptoms of stroke or sudden decline. In this case, a cognitively intact female resident with a history of postprocedural hemorrhage, repeated falls, tinea pedis, and encephalopathy began experiencing increased left leg weakness and vision problems. These symptoms were new and represented a significant change from her baseline, as she typically did not require assistance with ambulation or transfers. On the day of the incident, the resident reported worsening vision and left leg weakness, requiring two staff members to assist her to the bathroom, which was out of character for her. Both CNAs who assisted her recognized the change and notified the LPN on duty. Despite these new symptoms and the resident's complaints, the LPN decided to monitor the resident rather than immediately notify the provider, citing that the nurse practitioner had seen the resident the previous day for similar but less severe complaints. The LPN did not call the physician or nurse practitioner at that time, even though the resident's condition continued to deteriorate throughout the day. It was only after the resident developed additional symptoms, including flaccidity of the left arm and further decreased mobility, that the LPN contacted the nurse practitioner and arranged for the resident to be sent to the emergency department. Hospital records confirmed the resident had suffered an acute ischemic stroke. Interviews with staff and the resident confirmed that the provider was not notified promptly when the significant change in condition first occurred, resulting in a delay in evaluation and treatment.