Failure to Notify Physician After Significant Change in Resident Condition
Penalty
Summary
The facility failed to immediately notify a resident's physician following significant changes in the resident's physical status, specifically after two hypoglycemic episodes. The first episode occurred when the resident was found unresponsive with a blood sugar of 40, and glucagon was administered by an LPN. The LPN did not notify the physician at that time, believing the situation was resolved after the resident's blood sugar normalized and the resident ate breakfast. Documentation of the event was limited to the shift change report, and no direct communication with the physician occurred. Later, the resident experienced a second, more severe hypoglycemic episode during the following shift, where the resident was found unresponsive, hardly breathing, and foaming at the mouth. Emergency services were called, CPR was initiated, and the resident was transported to the hospital with a blood sugar of 27. The physician was not notified of the initial hypoglycemic event or the subsequent change in condition until after the second, critical episode had occurred and the resident had already been sent to the hospital. Interviews confirmed that the physician and physician's office were not contacted regarding the resident's initial hypoglycemic episode, and the physician stated that he would have altered the resident's diabetes management had he been informed. The facility's policies required immediate physician notification for significant changes in condition, including hypoglycemic episodes, but these protocols were not followed by staff. The resident's care plan and physician orders included specific instructions for diabetes management and hypoglycemia response, which were not fully adhered to in this case.