Failure to Notify Physician of Significant Change in Resident Condition
Penalty
Summary
The facility failed to ensure timely physician notification of significant changes in condition for two residents. For one resident with multiple complex diagnoses, including COPD, diabetes, heart failure, and cancer, there was an order for full code status and hospice admission. The resident experienced coffee ground emesis, hypotension, and tachycardia, and while hospice was notified, there was no documentation that the physician was informed of these acute changes. The medical director later confirmed he was not made aware of the resident's deteriorating condition and stated that, had he been notified, he would have recommended transfer to the emergency room for evaluation. In a separate incident, another resident with a history of diabetes, COPD, heart disease, and stroke reported chest pain and constipation to an LPN during morning medication administration. The LPN checked vital signs and advised the resident to go to the ER, but the resident refused. Later, the resident was found unresponsive on the bathroom floor, and CPR was initiated before EMS arrived. There was no documentation that the physician was notified of the resident's chest pain prior to the unresponsive event. The medical director confirmed he was not informed of the chest pain, despite the resident's history of noncompliance with care. Facility policy required nursing staff to notify the physician of significant changes in a resident's condition, including accidents, injuries, adverse reactions, and major declines in health status. In both cases, the required physician notification did not occur as outlined in policy, resulting in a deficiency related to communication of changes in resident condition.