Failure to Notify Physician and Monitor Resident After Refusal of STAT Labs and Ongoing Symptoms
Penalty
Summary
The facility failed to notify the physician when a resident refused immediate (STAT) laboratory tests on two occasions, and there was no documentation in the electronic medical record (EMR) that the refusals were communicated to the provider. Additionally, the facility did not obtain a urine specimen for a urinalysis with culture and sensitivity as ordered, nor was there evidence that the physician was notified of the failure to collect the specimen. The resident, who was cognitively intact and had a history of myelodysplastic syndrome, anemia, and acute congestive heart failure, experienced ongoing symptoms including nausea without vomiting for three days, decreased appetite, and persistent diarrhea. Despite these symptoms, the facility did not adequately monitor the resident for changes in condition. Nursing notes indicated that the resident had decreased appetite and diarrhea for several days, and while Imodium was ordered for the diarrhea, there was no evidence of further assessment or monitoring after a late entry note documented the resident's ongoing symptoms. A critically high white blood cell (WBC) count of 26.4 K/CU.MM was reported, but there was no documentation that this result was acted upon or that follow-up laboratory tests were ordered as recommended by a nurse practitioner. The resident was later found unresponsive and was pronounced deceased, with the death certificate listing suspected sepsis due to diarrhea and hypokalemia as causes of death. Interviews with staff and family members revealed communication breakdowns and a lack of timely response to the resident's declining condition. Family members reported requesting hospital transfer, which was denied by staff who stated the physician did not approve it, and they were not informed of their right to call 911 themselves. The facility's own policies required timely laboratory services and provider notification, but these were not followed, contributing to the resident's unmonitored decline and subsequent death.
Removal Plan
- Educate licensed nurses on documentation and provider notification requirements when residents refuse diagnostic testing or exhibit changes in condition
- Educate licensed nurses on acute changes in condition protocol and documentation requirements
- Educate licensed nurses on honoring resident's/family rights to transfer to hospital when requested, including the obligation to inform providers and document the decision in the electronic medical record (EMR)