Failure to Timely Notify Physician of Resident Change in Condition and Elopement
Penalty
Summary
The facility failed to ensure timely physician notification for two residents following significant changes in their condition or incidents. In the first case, a resident with multiple complex diagnoses, including chronic embolism, atrial fibrillation, hypertension, left above knee amputation, dementia, and a history of traumatic brain injury, experienced severe pain after returning from a chiropractor appointment. Nursing documentation indicated that the resident was screaming in pain with minimal movement, and the pain was localized to the right knee. Despite repeated reports of pain and the resident's refusal to be repositioned, the physician was not notified on the day of the incident. The nurse deferred to the resident's POA, who advised that physician notification was unnecessary. The physician was not informed until the following day, after which the resident was sent to the hospital and diagnosed with a femur fracture requiring surgery. In the second case, another resident with dementia, major depressive disorder, chronic respiratory failure, and other comorbidities eloped from the facility. The resident was found outside the facility by a family member of another resident and expressed intentions to travel out of state. The incident report was incomplete, lacking documentation of a registered nurse assessment, vital signs, and mental status evaluation. The physician was not notified of the elopement at the time of the incident, and there was no evidence that the physician was made aware during a subsequent monthly compliance visit. Notification to the medical director and a body check were not completed until six days after the elopement. Both incidents demonstrate a failure to promptly notify the physician of significant changes in resident condition or incidents, as required. In the first case, the nurse relied on the POA's direction rather than clinical judgment and facility policy, resulting in delayed medical intervention. In the second case, the lack of immediate physician notification and incomplete incident documentation following an elopement further contributed to the deficiency.