Failure to Ensure Timely Physician Oversight and Assessment After Change in Condition
Penalty
Summary
A deficiency occurred when the facility failed to ensure proper physician supervision and oversight of medical care for a resident who experienced a change in condition. Specifically, an order for ciprofloxacin ophthalmic drops was entered by a Registered Nurse Supervisor after a family representative reported redness in the resident's right eye. There was no documented nursing or physician assessment at the time the order was entered, and the physician was contacted by text message without documentation of notification in the medical record. The antibiotic treatment was initiated the following day without a provider evaluation, and the resident was not seen by a medical provider until six days after the change in condition was identified and treatment had already begun. The resident involved had diagnoses including dementia, anemia, and cardiac arrhythmias, with severe cognitive impairment and extensive assistance needs. The facility's policy required physician review and documentation of orders, as well as evaluation of residents as clinically indicated, but these steps were not followed. Interviews confirmed that there was no documented assessment or timely provider evaluation, and no documentation of an ophthalmology referral or visit was found. The lack of timely physician oversight and documentation led to the deficiency cited under 10 NYCRR 415.15(b)(1)(i)-(ii).