Failure to Notify Physician of Significant Change in Resident Condition
Penalty
Summary
The facility failed to notify a resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status, specifically when the resident experienced multiple episodes of low blood pressure, low heart rate, and low blood pressure with increased heart rate over several days. Despite repeated abnormal vital signs and the holding of blood pressure medications due to these readings, there was no documented evidence that the physician was consistently notified as required by facility policy. The resident's care plan and medication orders clearly indicated the need for monitoring and reporting such changes, but this was not followed. The resident involved had a complex medical history, including dementia, gastrointestinal hemorrhage, iron deficiency anemia secondary to blood loss, hypertension, and acute embolism and thrombosis of deep veins. The resident was on anticoagulant and antihypertensive therapies, with specific parameters for holding medications based on vital signs. Over a period of several days, the resident's vital signs were repeatedly outside of these parameters, and medications were held accordingly. However, the process for escalating these findings to the physician was inconsistent, with staff interviews revealing confusion about notification responsibilities and a lack of documentation of physician contact in the clinical record. On one occasion, the resident was found to have critically low hemoglobin and hematocrit levels and was subsequently sent to the emergency room, where a gastrointestinal hemorrhage was diagnosed and a blood transfusion was administered. Interviews with staff and review of records indicated that the physician was not adequately informed of the ongoing abnormal vital signs and medication holds prior to this acute event. The facility's own policies required immediate physician notification for significant changes in status and for any held doses of regularly scheduled medication, but these procedures were not followed, leading to a deficiency finding by surveyors.