Failure to Provide Timely Emergency Response and Clinical Notification
Penalty
Summary
The facility failed to ensure that services provided met professional standards for two residents, resulting in actual harm. In the first case, a cognitively intact resident with multiple diagnoses, including cancer and diabetes, was found on the floor after a fall, unable to move their arms or legs, and with a small amount of blood behind the head. Despite these significant symptoms, including complaints of nausea, numbness, and inability to maintain upper body balance, staff did not call emergency medical services. Instead, the resident was lifted by several staff members into a wheelchair and transported to the emergency room in the facility van, accompanied by a CNA and the activities director. Staff interviews revealed that the decision not to call 911 was based on cost and perceived convenience, even though the resident exhibited signs of a possible spinal injury and head trauma. The nurse practitioner was not notified of the fall or the need for hospital transport at the time of the incident. In the second case, another resident with complex medical needs, including malnutrition, fractures, chronic respiratory failure, and a urinary catheter, experienced a significant decline in condition. The care plan indicated the resident required extensive assistance for mobility and toileting, and monitoring for signs of urinary tract infection (UTI). Despite orders for laboratory tests and a urinalysis, the urine sample was not obtained as directed. Over several days, nursing staff documented decreased urinary output, increased drowsiness, and changes in mental status. When a nurse reported these changes and recommended hospital transfer, she was instructed by the staff development coordinator to wait for the night nurse's opinion, delaying the transfer. The nurse was also told not to contact the provider, and her ability to make clinical decisions was limited by management. The resident was eventually transferred to the hospital after further decline, but the nurse practitioner was not notified of the change in condition prior to transfer, and the urinalysis was not completed until arrival at the hospital. Facility policies required prompt notification of physicians and families following significant changes in resident condition, including falls and clinical deterioration. However, in both cases, there was a failure to follow these protocols, resulting in delayed medical evaluation and intervention. Staff interviews confirmed that decisions regarding emergency transfers were influenced by non-clinical factors such as cost and convenience, and that communication with providers was inadequate during critical events.