Failure to Notify Provider of Change in Condition for Two Residents
Penalty
Summary
The facility failed to notify a medical provider of a change in condition for two of seven residents, as required by facility policy and state regulations. For one resident with diagnoses of high blood pressure and heart failure, clinical records showed that the resident's oxygen saturation remained below 77% throughout a shift, despite being on continuous oxygen therapy. The nurse on the previous shift did not notify the physician of the resident's persistently low oxygen levels. The issue was only addressed during the following shift, when the physician was informed and the resident was subsequently sent to the hospital for further care. For another resident with chronic obstructive pulmonary disease (COPD) and heart failure, the facility failed to notify the provider of a significant weight gain of approximately fifteen pounds over four weeks, as well as other symptoms such as increased abdominal distention, shortness of breath, and +3 lower leg edema. Although a one-time order for Lasix was received, there was no documentation of provider notification regarding the weight gain or the change in the resident's condition prior to the resident being transported to the hospital for COPD exacerbation and right-sided heart failure. Interviews with facility staff, including the Medical Records employee, confirmed that there was no documentation of provider notification for these changes in condition. The Nursing Home Administrator and Director of Nursing also acknowledged the failure to notify the medical provider as required. These findings were based on a review of facility policies, clinical records, and staff interviews.