Failure to Notify Physician and Resident Representative of Change in Condition and Incident
Penalty
Summary
The facility failed to notify the physician and the resident's representative of a significant change in condition and an incident that potentially required physician intervention. Specifically, a resident had an abnormally high white blood cell (WBC) count, which was not reported to the physician or the resident's representative, and no change of condition report was initiated. Additionally, the resident, who was on an NPO (nothing by mouth) diet due to difficulty swallowing, was found with a grape ice pop in hand and a large piece in the mouth. This incident was not documented as a change in condition or incident, and neither the physician, nurse practitioner, nor the resident representative was notified. A review of the facility's policies indicated that nurses are responsible for reviewing and reporting abnormal lab results and significant changes in condition to the appropriate parties, including the physician and resident representative. The Director of Nursing confirmed that these notifications and required documentation were not completed for the resident in question. The failure to follow established protocols for notification and documentation led to the deficiency identified during the complaint survey.