Failure to Notify Primary Care Provider of Resident's Change in Condition
Penalty
Summary
A deficiency was identified when the facility failed to ensure that a resident received care in accordance with professional standards of practice, specifically regarding the notification of a primary care provider following a change in the resident's condition. The resident, who had multiple diagnoses including frontotemporal neurocognitive disorder, history of transient ischemic attack, depressive disorders, atrioventricular block, osteoporosis, hypothyroidism, hypertension, and hypokalemia, experienced black, tarry, and foul-smelling stools and increased weakness over a two-day period. Progress notes documented these changes, but there was no evidence in the medical record that the resident's primary care provider was notified of this significant change in condition. Interviews with nursing staff and the Director of Nursing confirmed that the facility's protocol required notification of the primary care provider and documentation of this action in the resident's medical record. However, review of the records showed no such documentation, and the relevant check box in the electronic medical record system, which would have flagged the issue for physician review, was not selected. The Director of Nursing was unable to explain the lack of documentation or notification, and staff interviews did not provide evidence that the required notifications had occurred.