Failure to Promptly Address and Report Resident Hypothermia
Penalty
Summary
A deficiency occurred when staff failed to promptly address and notify the physician regarding a resident's hypothermia. The resident, who had a diagnosis of hypothermia, was first noted by a CNA to have a low temperature of 92°F at 9:30 A.M. The Licensed Nurse (LN) on duty was informed but did not immediately assess the resident, instead instructing the CNA to retake the temperature. At around 11:00 A.M., the resident's temperature had dropped further to 90.2°F, and the resident was observed to be shivering with cold skin. The LN initiated a change of condition assessment and notified the physician only around 12:00 P.M., after which the resident was transferred to the hospital. Interviews with staff, including the Director of Nursing (DON) and another LN, confirmed that the resident's low temperature should have been addressed and the physician notified immediately, as hypothermia is a medical emergency. The facility's policy requires all changes in resident condition, including unusual signs and symptoms, to be promptly communicated to the physician. The delay in assessment and notification resulted in a delay of treatment for the resident.