Failure to Ensure Timely Physician Oversight and Response for Resident Care
Penalty
Summary
The facility failed to ensure that a resident was under the care of a physician who would provide timely orders and respond promptly to notifications regarding elevated blood sugars, abnormal lab results, and the administration of intravenous (IV) medication for infection. The resident in question had significant medical conditions, including diabetes, septicemia, renal failure, and aphasia, and required complex care such as insulin management and IV antibiotics following a hospital discharge for sepsis and a large retroperitoneal abscess. The discharge summary included a specific order for daily IV antibiotics, but documentation showed repeated issues with the resident removing IV lines and delays in replacing them, as well as changes in medication orders without clear or timely communication from the provider. Nursing notes and medication records revealed multiple instances where the resident experienced critically high blood sugar levels, with staff making repeated attempts to contact the provider for guidance. In several cases, messages were left without timely responses, and there were documented difficulties in reaching the provider or receiving actionable orders. Staff interviews confirmed that the provider was often unresponsive, sometimes taking days to return calls, and that staff had to escalate urgent issues to the Medical Director or repeatedly attempt contact. There were also communication gaps regarding new medication orders and diagnostic results, with staff sometimes unaware of new orders or not receiving reports directly. The facility's policy required that a physician or nurse practitioner supervise residents' medical care and be available 24 hours a day for emergency care. However, both nursing staff and the Director of Nursing reported ongoing problems with provider responsiveness and unclear points of contact, resulting in delays in care and uncertainty about the resident's treatment plan. These failures led to lapses in the timely management of the resident's acute and chronic medical needs.