Failure to Notify Physician of Significant Change in Resident's Condition
Penalty
Summary
The facility failed to notify a resident's physician of a significant change in condition, specifically the development of constant left hip pain that worsened with movement and limited mobility, following an unwitnessed fall. The resident, who had multiple diagnoses including acidosis, major depressive disorder, muscle weakness, and cognitive communication deficits, was assessed as having moderately impaired cognition. The care plan required staff to monitor for pain, encourage reporting, and notify the physician if pain interventions were unsuccessful or if the pain was a significant change from the resident's past experience. On the day of the incident, the resident reported constant left hip pain rated as five out of ten at rest and eight out of ten with movement, and was unable to move the left leg through its full range of motion. Documentation showed that the resident's family and physician were notified of the fall, but there was no documentation that the physician was notified of the new or worsening pain. The unit manager instructed the primary nurse to notify the physician and obtain an order for pain medication, but this was not done, and no pain medication order was obtained. The nurse practitioner later ordered an x-ray, and the resident was eventually sent to the hospital for evaluation of left hip pain. Interviews with facility staff confirmed that the responsibility to notify the physician and obtain pain medication orders was not fulfilled, and the facility's policies required prompt notification of the physician for significant changes in condition or new pain. The director of nursing acknowledged that the required notifications and documentation were not completed, and that the facility's policies and procedures were not followed in this instance.