Failure to Notify Physician of Significant Change in Resident Condition
Penalty
Summary
The facility failed to notify a resident's physician of a significant change in the resident's condition, specifically the development of multiple bruises over several weeks. The resident, an elderly female with diagnoses including sepsis, cognitive decline, atherosclerotic heart disease, and dementia, was on anticoagulant and antiplatelet therapy, which increased her risk for bleeding and bruising. Despite care plan and physician orders requiring staff to monitor for and report signs of bruising or bleeding, documentation showed that a nurse recorded the presence of multiple bruises on the resident's arms and legs on three separate weekly skin assessments but did not notify the physician as required. Observations and interviews confirmed that the resident had extensive bruising on both arms, which had been present for about 15 days. The resident was unable to recall the cause of the bruises and was noted to have severe memory impairment. Staff interviews indicated that the resident was known to bruise easily, and protective measures such as geri sleeves were used. However, the nurse responsible for the resident's care acknowledged that she had not communicated the bruising to the physician, despite being aware of the ongoing issue and the care plan's instructions. The Director of Nursing (DON) confirmed that the nurse should have completed an incident report and notified both the DON and the physician about the bruising. The resident's primary physician stated he was not made aware of the recent bruising until notified by the DON, and he indicated that he would have provided different medical orders had he been informed earlier. Facility policy required timely physician notification and documentation of significant changes in resident status, which was not followed in this case.