Failure to Notify Physician and Representative After Resident's Change in Condition
Penalty
Summary
The facility failed to immediately notify a resident's physician and responsible party when the resident experienced a significant change in condition. The resident, a male with diagnoses including type 2 diabetes mellitus, chronic kidney disease, degenerative nervous system disease, chronic pancreatitis, depression, and muscle weakness, began experiencing severe symptoms such as vomiting, chest pain, and a high fever. Multiple staff and residents reported the resident's deteriorating condition to the assigned nurse, but the nurse did not promptly assess the resident or notify the physician or the resident's representative. The certified nurse aide (CNA) observed the resident doubled over, with grayish skin and severe pain, and after waiting over an hour for the nurse to respond, called 911 herself. The nurse only entered the resident's room shortly before emergency medical services arrived. Documentation showed that the nurse recorded the resident's symptoms and transport to the hospital but did not document any notification to the physician or the resident's representative. The nurse later stated she may have left a message for the physician after the resident was taken to the hospital but did not contact the resident's representative and had no reason for not doing so. Interviews with the nurse practitioner and the resident's family confirmed that neither the physician nor the resident's emergency contact were notified at the time of the incident. The nurse practitioner indicated that earlier notification could have allowed for intervention. The facility's own policy required prompt notification of significant changes to both the physician and the resident's representative, but this was not followed in this case.