Failure to Notify Physician of Change in Condition and Medication Error
Penalty
Summary
A deficiency occurred when facility staff failed to immediately notify a resident's physician of a significant change in the resident's physical status. The resident, an elderly male with a history of Ogilvie Syndrome, ileostomy, hypokalemia, atherosclerotic heart disease, and congestive heart failure, began passing large amounts of watery fluids through his ileostomy, which was a new symptom for him. Despite this change, the nurse on duty did not contact the physician, nor was there documentation of physician notification in the resident's chart. The nurse also administered losartan potassium outside of the prescribed blood pressure parameters and did not report this medication error to the physician. The resident's family member noticed the change in the resident's condition, including altered breathing, pallor, and weakness, and brought these concerns to the nurse's attention. The nurse took the resident's vital signs, which showed low blood pressure, but reassured the family member that the situation was not critical and stated that labs would be obtained in the morning. The family member also reported that the resident had similar symptoms previously when he was dehydrated and had low potassium, but no immediate action was taken by the nurse to notify the physician or escalate care. Later, the resident was found unresponsive and subsequently pronounced dead. The physician confirmed that she was not notified of the resident's change in condition or the medication error, and stated that she would have ordered immediate labs and considered sending the resident to the emergency room had she been informed. Facility policy required immediate notification of the physician for significant changes in condition and for medication errors, but these procedures were not followed in this case.