Failure to Notify Physician and Assess Residents After Change in Condition
Penalty
Summary
The facility failed to ensure timely notification to physicians regarding changes in residents' conditions, as well as appropriate assessment and monitoring following significant incidents. In one instance, a resident with a history of substance use was found by a CNA and two LPNs to be smoking an illicit substance in his bathroom. The staff observed the resident using drug paraphernalia and blowing smoke in the face of a nurse. The police and facility administration were notified, and the paraphernalia was confiscated. However, there was no documentation of any restrictions or interventions implemented to prevent further drug use by the resident, nor was there evidence of increased monitoring to protect other residents, including the roommate who was present during the incident. The roommate, who had multiple respiratory diagnoses and required continuous oxygen therapy, was not assessed immediately after the exposure to the illicit substance. The initial assessment of this resident was not completed until the following day, and vital signs taken at that time showed the lowest blood pressure recorded for the resident in the reviewed timeframe. There was no documentation that the physician or nurse practitioner was notified of this abnormal finding. Interviews confirmed that the expected protocol of immediate assessment and notification was not followed, and the resident was not awakened or physically assessed during the night following the incident, despite the potential for exposure to harmful substances. In another case, a resident receiving antibiotic therapy for a toe infection experienced nausea and vomiting after starting the medication. The resident reported vomiting to a CNA, who disposed of the vomit but did not inform the charge nurse until prompted during an interview. The nurse was unaware of the resident's symptoms until later in the morning, and there was no evidence of timely assessment or physician notification regarding the adverse reaction. The facility's policy required prompt notification of changes in condition, but this was not adhered to in these cases.