Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
Facility staff failed to notify a resident's physician when the resident reported numbness and weakness on the right side of her face. The resident, who had diagnoses including chronic respiratory failure, type 2 diabetes, ventilator dependence, and hypertensive heart disease, was cognitively intact and dependent on staff for activities of daily living. On the evening in question, the resident informed a registered nurse (RN) of her symptoms. The RN assessed the resident for signs of stroke, found none, and educated the resident on stroke symptoms, but did not notify the physician. The RN later acknowledged that she should have contacted the physician but failed to do so at the time. The resident continued to experience symptoms over the weekend and reported them again to a different RN, who then notified the physician and arranged for the resident to be transferred to the emergency department, where she was diagnosed with Bell's Palsy. The facility's policy required timely notification of the physician and resident representative in the event of significant changes in a resident's condition. The Assistant Director of Nursing confirmed that the physician should have been notified immediately and that there was a delay in care and treatment.