Failure to Communicate Change in Condition and Pertinent Information to Physician
Penalty
Summary
The facility failed to ensure that staff communicated all pertinent information to a physician regarding a resident who experienced a fall and subsequent change in condition. According to facility policy, staff are required to promptly notify the resident, their attending physician, and the resident representative of any significant changes in the resident's condition, including accidents, incidents, or changes in physical or mental status. In this case, a resident with a history of dysphagia, aphasia, COPD, atrial fibrillation, cardiovascular disease, and congestive heart failure, who was also on anticoagulant medication, experienced a fall from bed and vomited twice around the time of the fall. Documentation and interviews revealed that after the fall, the nurse completed a change in condition assessment and notified a nurse practitioner (NP) about the resident's elevated pulse and low oxygen saturation, but did not communicate the occurrence of the fall or the vomiting episodes. The NP ordered laboratory tests and medication administration based on the information provided, but was not made aware of the fall or the resident's anticoagulant use at that time. Multiple staff interviews confirmed that there was an assumption among nurses that the fall had already been reported to the provider, leading to incomplete communication. The DON and other staff acknowledged that vomiting after a fall and the use of anticoagulants were significant details that should have been reported to the provider. Further interviews with the NP and the medical director confirmed that if they had been notified of the fall and vomiting, they would have considered holding the anticoagulant medication and would have asked additional questions. The lack of complete and accurate communication prevented the provider from making a fully informed decision regarding the resident's care. The resident was later found unresponsive and expired, with documentation and staff interviews indicating that critical information was not relayed to the provider as required by facility policy.