Failure to Notify Physician of Significant Changes in Resident Condition
Penalty
Summary
The facility failed to notify physicians in a timely manner regarding significant changes in condition for multiple residents, including the development of new pressure ulcers, a diabetic foot ulcer, and significant weight loss. In one case, a resident with a history of cerebral vascular accident and diabetes developed a pressure ulcer on her right heel, which was first observed by a nurse aide and nurse, but the physician was not notified until several weeks later when the wound had progressed to an unstageable ulcer with black eschar and foul odor. The wound nurse and medical director confirmed that they were not made aware of the wound until much later, and there was no documentation of earlier physician notification in the medical record. Another resident with vascular dementia and hemiparesis was found to have an unstageable open area on the left heel by the wound nurse, who treated the wound with standing orders and notified the wound nurse practitioner the following day. However, the resident's nurse practitioner and medical director were not notified of the new wound or subsequent lab results, and both stated they should have been informed to initiate appropriate interventions. Similarly, a resident with dementia and malnutrition experienced significant weight loss, but the physician was not notified promptly. The assistant director of nursing acknowledged responsibility for notifying the physician but admitted the notification was delayed due to waiting for a reweight and being busy with other tasks. Additionally, a resident with multiple sclerosis and hemiplegia reported a stage II pressure ulcer to the back of his thigh, which was documented and treated by a nurse without notifying the physician. The nurse believed the process was to enter a treatment order and document in the acute book, but not to notify the provider directly. The assistant director of nursing, nurse practitioner, and medical director all confirmed that the physician should have been notified of the new wound. These failures to notify the physician of significant changes in condition affected all four residents reviewed for notification.