Failure to Notify Physician of Significant Changes and Treatment Alterations
Penalty
Summary
The facility failed to immediately notify the physician of a significant change in condition for a resident who was receiving antiplatelet medications, specifically Plavix and aspirin. The resident, who had a history of type-2 diabetes, chronic kidney disease, peripheral vascular disease, and atherosclerotic heart disease, developed a large purple/blue bruise on the left lower quadrant of the abdomen. Multiple nursing staff, including a nurse, two unit managers, and another nurse, observed or were informed of the bruise over the course of several days but did not notify the provider. The nurse practitioner was not made aware of the bruising until two days after it was first observed, at which point the resident was seen in clinic. Additionally, the facility failed to notify the physician before discontinuing a continuous enteral feeding for another resident with diabetes and a gastrostomy. Nursing staff stopped the tube feeding early on multiple occasions in response to elevated blood glucose readings, without obtaining a physician's order or notifying the provider. Nurses believed it was within their judgment to stop the feeding and did not consider it necessary to contact the provider, even when blood glucose levels were significantly elevated and there were no sliding scale insulin orders in place. Interviews with the nurse practitioner, medical director, DON, and administrator confirmed that the expectation was for nurses to administer tube feedings as ordered and to notify the provider for elevated blood sugars or before making changes to physician-ordered treatments. Documentation and staff interviews revealed a pattern of not notifying the provider as required for both the bruising incident and the management of tube feedings in response to high blood glucose levels.