Failure to Timely Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to ensure timely notification to the physician when a resident exhibited a significant change in condition. The resident, who had diagnoses including malignant neoplasm of the colon and liver, was admitted to hospice care and had impaired cognition and depression. According to the care plan, staff were to monitor and report any risk for self-harm or suicidal ideation. On the night in question, a certified nursing assistant found the resident with a call light cord around his neck, which was a notable change from his baseline behavior. The registered nurse on duty was alerted and removed the cord, then notified the resident's physician, hospice, and family member. However, the nurse initially texted the physician after the incident but did not receive a response and did not make a phone call to the physician until over eight hours later. During this time, the resident was monitored by staff and hospice was contacted, but the delay in direct physician notification was contrary to facility policy, which required immediate phone notification in the event of an acute change in condition. Interviews with staff confirmed that any suspected self-harm or suicidal ideation should prompt immediate physician notification by phone, and the facility's policy specified that if the physician could not be reached within thirty minutes, emergency services should be contacted. The deficiency was identified through record review, observation, and interviews, and was found to be a continuation of non-compliance from a previous survey.