Failure to Assess and Notify Physician for Suspected GI Bleed
Penalty
Summary
A deficiency occurred when an LPN failed to follow facility policy and practice within the scope of licensure after a family member raised concerns about a resident potentially experiencing a gastrointestinal (GI) bleed, as evidenced by black, pasty stools. The LPN documented the family’s concern and attributed the symptoms to new medications but did not assess the resident, notify the physician, or contact on-call leadership staff, despite facility policy requiring immediate physician notification for bleeding or bloody stools not due to hemorrhoids. There was no documentation of an assessment or escalation of the concern on the evening the issue was reported. The resident involved had multiple co-morbidities, including osteomyelitis, long-term anticoagulant use, diabetes with polyneuropathy, peripheral vascular disease, congestive heart failure, hypertension, and atrial fibrillation. Upon admission, the resident was alert, oriented, and had stable vital signs, receiving IV antibiotics and regular lab monitoring. Lab results showed a significant drop in hemoglobin over several days, and the resident was dependent on staff for toileting. Despite the family’s report of black, tarry stools, there was no documentation of such findings in the medical record, and the required assessment and physician notification were not performed promptly. Interviews with other nursing staff and the DON confirmed that the expected protocol was to assess the resident and notify the physician or on-call leadership when concerns were raised by family members. The facility’s policy specified immediate physician notification for suspected GI bleeding. The LPN’s failure to assess the resident and escalate the concern as required led to a delay in appropriate medical intervention and contributed to the identified deficiency.