Failure to Notify Physician After Resident's Significant Change in Condition
Penalty
Summary
A deficiency occurred when facility staff failed to notify a resident's physician following significant changes in the resident's physical and mental status. The resident, an elderly female with a history of end-stage renal disease, hypertension, diabetes mellitus, and urinary tract infection, was found lethargic with a critically low blood sugar level. Despite the severity of her condition, including an unregistered blood sugar reading and subsequent administration of glucagon, the physician was not contacted for guidance or orders. EMS was called, and the resident was stabilized on the unit, but there was no documentation of physician notification or further medical assessment at that time. The following day, the same resident experienced another severe episode, being found unresponsive with a blood sugar reading of 21. Glucagon was administered again, and EMS was called, resulting in the resident's transfer to a local hospital where she was treated for hypoglycemia and altered mental status. Nursing notes revealed a lack of ongoing monitoring, assessment, and documentation between the two events, with no SBAR communication or follow-up notes recorded. Interviews with staff confirmed that the physician was not notified during either event, and there was a failure to monitor the resident's blood sugar at appropriate intervals or document her level of consciousness and intake. The facility's policy required immediate physician notification for acute or significant changes in condition, as well as the use of SBAR tools and proper documentation. However, these procedures were not followed. Staff interviews indicated uncertainty about the policy and a lack of follow-up after the initial event. The attending physician confirmed she was not notified and emphasized that the resident's blood sugar levels were critically low and required immediate medical attention and monitoring, which did not occur.