Delayed Physician Notification After Resident's Change in Condition
Penalty
Summary
The facility failed to notify a physician in a timely manner following a significant change in a resident's condition. The resident, who had a history of congestive heart failure, COPD, and obstructive sleep apnea, was found lethargic, slow to respond, and unable to eat or take medications. Vital signs showed low oxygen saturation, and the respiratory therapist documented that the resident was not wearing the oxygen cannula properly, resulting in a SpO2 of 67%. Interventions were initiated, including the use of a non-rebreather mask, which improved the resident's oxygen saturation. Despite these interventions and the resident's continued lethargy and inability to take medications, the physician was not notified immediately. Documentation revealed that the resident's condition remained concerning throughout the morning, with multiple staff members, including the respiratory therapist, nurse, and nursing supervisor, being made aware of the situation. The resident was unable to participate in incentive spirometry and continued to be lethargic and unresponsive to commands. The physician was not contacted until the resident's daughter arrived in the early afternoon, expressed concern, and requested that the resident be sent to the hospital. Only at that point was the physician notified and orders obtained for hospital transfer. Interviews with facility staff confirmed that the expected protocol for a change in condition, such as desaturation and lethargy, was to assess the resident and notify the physician promptly. However, in this case, there was a delay of approximately three to four hours between the initial episode of desaturation and the notification of the physician. Facility policy also required immediate notification of the physician and the resident's representative in the event of a significant change in condition, which was not followed in this instance.