Failure to Immediately Notify Provider and Representative of Resident Change in Condition
Penalty
Summary
The facility failed to immediately notify a resident's physician and representative when a significant change in the resident's condition was reported. A family member contacted the facility after noticing the resident had slurred speech and altered mental status. The nurse on duty assessed the resident but did not document the family’s concerns or her assessment, nor did she notify the provider or communicate the event to the next shift. There was no documentation of any changes in the resident’s condition in the 24-hour report or progress notes for that day. The following day, the family member followed up and again expressed concern. The nurse practitioner was then notified, assessed the resident, and, after discussion with the family, arranged for the resident to be sent to the hospital for evaluation. Upon hospital admission, the resident was diagnosed with an acute ischemic stroke. Prior to this event, the resident had a history of metabolic encephalopathy, difficulty walking, and high blood pressure, but was able to ambulate with supervision and had only moderate cognitive impairment. Interviews with facility staff revealed that the nurse on duty at the time of the initial report did not follow facility policy regarding documentation and notification of changes in condition. The nurse practitioner and DON confirmed that immediate notification of the provider and documentation are required when a change in condition is reported, regardless of the day of the week. The delay in notification and lack of documentation resulted in a delay in the identification and treatment of the resident’s stroke.