Failure to Notify Physician and Responsible Party of Resident's Change in Condition
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including urinary tract infection, congestive heart failure, and chronic respiratory failure with hypoxia, experienced a change in condition marked by a fever of 100.2°F. The resident, who had severely impaired cognition as indicated by a BIMS score of 3 out of 15, had this elevated temperature recorded on the Medication Administration Record (MAR) during the 11-7 shift. However, there were no corresponding nursing notes, no follow-up temperature checks, and no documentation of any actions taken in response to the fever during that shift. Further review revealed that neither the resident's physician nor the responsible party was notified of the fever, as required by facility policy. Interviews with nursing staff and the Director of Nursing confirmed that the expected protocol in such situations includes documenting the event, monitoring the resident, notifying the physician and family, and administering Tylenol if indicated. The facility's policies also require documentation of all services provided and notification of significant changes in a resident's condition. These steps were not followed in this instance, resulting in a failure to notify the appropriate parties of the resident's change in condition.