Failure to Timely Notify Physician of Change in Resident Condition
Penalty
Summary
A deficiency occurred when the facility failed to promptly notify a resident's physician of a significant change in condition. The resident, who had multiple medical diagnoses including dementia, major depressive disorder, COPD, diabetes, osteoporosis, heart failure, and hypertension, was admitted with severely impaired cognition and required assistance with activities of daily living. On two consecutive days, the resident complained to two CNAs about increased pain and swelling in her left knee, which prevented participation in daily activities. Both CNAs observed the swelling and reported it to the nurse on duty. The RN assessed the knee and administered routine pain medication but did not notify the physician, attributing the symptoms to cellulitis for which the resident was already being treated. Subsequent review and interviews revealed that the cellulitis was unrelated to the resident's knee, as it was associated with a wound on the lower leg. The physician and CNP were not informed of the increased pain and swelling until several days later, at which point an x-ray revealed distal fracture fragments and the resident was sent to the emergency room for further evaluation. The failure to timely report the change in condition to the physician was confirmed through closed medical record review and staff interviews, affecting one resident out of three reviewed for change in condition.