Failure to Notify Physician of Change in Condition and Representative of Medication Changes
Penalty
Summary
Facility staff failed to promptly notify a physician when a resident experienced a significant change in condition. One resident with a history of traumatic brain injury, heart failure, and renal failure was noted as difficult to arouse and lethargic by a nurse, but no timely assessment or notification to the physician occurred. Multiple staff members, including a registered nurse and a geriatric nursing assistant, observed the resident to be unresponsive and reported that the assigned LPN had not taken immediate action or obtained vital signs. The resident was eventually found to have critically low blood pressure and was transferred to the hospital after emergency measures were initiated, but only after a significant delay and repeated prompting by other staff members. Additionally, the facility failed to notify a resident's representative when there were multiple changes to the resident's medication regimen. Medical record review showed several instances where antipsychotic and anti-anxiety medications were initiated or had their dosages increased, but there was no documentation that the resident's representative was informed of these changes. The Assistant Director of Nursing confirmed the lack of documentation regarding representative notification for these medication changes.