Failure to Notify Provider and Monitor Resident with COVID-19
Penalty
Summary
A deficiency occurred when a resident with multiple respiratory diagnoses, including pneumonia, COPD, and chronic respiratory failure, tested positive for COVID-19 and did not receive consistent monitoring and assessment for changes in condition as required by facility policy and physician orders. The resident, who had severe cognitive impairment and was on continuous oxygen therapy, exhibited several changes in symptoms and vital signs over several days, including new onset of wheezing, productive and non-productive cough, elevated temperatures, increased oxygen requirements, and changes in lung sounds. Despite these changes, there was no documentation that the provider was notified in a timely manner, as required by both facility policy and physician orders. The facility's policy required immediate provider notification for acute illness or significant changes in a resident's physical status, including new or worsening symptoms. Physician orders specifically directed staff to monitor for COVID-19 symptoms every shift and to notify the provider immediately if any symptoms were noted. However, documentation showed that after the resident tested positive for COVID-19, there were multiple instances where new or worsening symptoms were observed—such as changes in lung sounds, increased oxygen needs, and elevated temperatures—but the provider was not notified until the resident became minimally responsive and hypoxic several days later. Interviews with nursing staff and the DON confirmed that any new symptoms or changes from baseline, especially in a COVID-19 positive resident, should have prompted immediate provider notification and documentation. The failure to notify the provider and to document these communications was acknowledged by staff and leadership during interviews. The resident was ultimately transferred to the hospital in acute distress with hypoxia and altered mental status, but there was no evidence of provider assessment or intervention between the initial positive COVID-19 test and the emergency transfer.