Failure to Notify Physician of Change in Condition Resulting in Resident Death
Penalty
Summary
A deficiency occurred when the facility failed to immediately notify a physician of a significant change in a resident's physical condition. The resident, who had a history of chronic obstructive pulmonary disease (COPD), mild dementia, intermittent atrial fibrillation, sick sinus syndrome, and left shoulder pain due to degenerative joint disease, complained of radiating pain to his left arm, shoulder, and chest, and reported difficulty breathing. Despite these symptoms, which were documented by staff, there was no evidence that the physician was notified of the change in condition at the time it occurred. The nurse on duty administered as-needed medication but did not document which medications were given or what interventions were attempted. There was no assessment of the resident's pain using a pain scale, nor was there documentation of respiratory or cardiac assessments. The nurse did not follow up with the resident after the initial complaint, nor did he communicate the situation to the nurse coming on shift. Other staff members, including a CNA, observed the resident in distress and reported it to the nurse, but no further action was taken to escalate the situation or notify the physician. The following morning, the resident was found unresponsive and without a pulse, and was pronounced deceased. Documentation shows that the physician was not notified of the resident's change in condition until after the resident was found deceased. The facility's policy required immediate communication of status changes to licensed personnel and prompt assessment and physician notification, but these procedures were not followed in this case.
Removal Plan
- Conduct audits of residents' condition to ensure no changes
- Re-educate nursing staff regarding assessments, documentation, and physician notification