Failure to Notify Physician After Resident's Significant Change in Condition
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's physician was properly consulted following a significant change in the resident's physical status. The resident, who had diagnoses including dementia, strange and inexplicable behavior, and a history of homelessness, was at risk for wandering and had moderate cognitive impairment. The resident was found outside on the ground at the back of the building after falling from a third-story window and was subsequently sent to the hospital via 911. Facility policy required prompt notification and consultation with the resident's physician in the event of an accident resulting in injury or with the potential to require physician intervention. Although a nursing progress note indicated that the Medical Director was made aware of the incident, the Medical Director later stated they were not informed of the resident's transfer to the hospital until the resident was readmitted with multiple fractures. The nurse supervisor reported sending a message via a messaging application but did not follow up to confirm receipt, and there was no documented evidence of the message due to the application's message retention policy. Interviews with facility staff, including the Director of Nursing Services, confirmed that the physician should have been informed of the change in the resident's condition. The Medical Director stated that staff were instructed to call if a message was not acknowledged, but this protocol was not followed. As a result, the required physician consultation did not occur at the time of the significant change in the resident's status.