Failure to Immediately Notify Physician and Intervene for Resident's Significant Change in Condition
Penalty
Summary
A deficiency occurred when facility staff failed to immediately consult with a resident's physician following a significant change in the resident's condition, specifically when the resident experienced bleeding from multiple skin tears. The resident, an elderly female with a history of Alzheimer's disease, muscle weakness, chronic pain, hypertension, and impaired skin integrity, was known to have very fragile skin due to long-term prednisone use and bilateral leg edema. On the morning of the incident, certified nursing assistants (CNAs) discovered the resident bleeding from newly developed skin tears on her leg while providing care. The CNAs reported the bleeding to the assigned LVN, who was administering medications at the time and stated she would assess the resident after completing her medication pass. However, the LVN did not assess or intervene for the resident's bleeding before leaving her shift. The CNAs attempted to control the bleeding by wrapping a towel around the wound and expected the LVN to follow up. The LVN later contacted one of the CNAs at home to inquire about the severity of the wound, admitting she had forgotten to address the bleeding due to being busy with other tasks. The resident continued to bleed until the next shift, when an RN was notified by another CNA and immediately intervened to control the bleeding, noting that the resident had lost a significant amount of blood and required multiple bandage changes. There was no handover or report given to the oncoming staff regarding the resident's condition, resulting in a delay in care. Interviews with facility staff, including the Director of Nursing (DON) and the Administrator, confirmed that the LVN did not assess or provide timely intervention for the resident's bleeding, and that the resident was left unattended and bleeding for approximately two hours. The facility's policies required staff to identify, document, and report changes in resident condition, and to provide detailed shift-to-shift handovers, but these procedures were not followed in this instance. The deficiency was identified through observation, interviews, and record review, which documented the sequence of events and the lack of immediate physician notification and timely nursing intervention.