Failure to Notify Physician and Act on Family Request for Hospital Evaluation
Penalty
Summary
The facility failed to consult with a resident's physician when there was a significant change in the resident's physical status, specifically the development of ecchymosis and a blood-filled blister near the dialysis access site. The resident, who had a complex medical history including end-stage renal disease (ESRD) on hemodialysis, diabetes mellitus type II, anemia, GI bleed, and dementia, was noted to have a blood-filled blister and maroon ecchymosis on the chest after returning from dialysis. The initial response by nursing staff was to notify the Nurse Practitioner (NP), who ordered wound care and antibiotics, but did not address the request for hospital evaluation made by the dialysis nephrologist and the resident's family. Despite multiple notifications from the dialysis center and the resident's family, nursing staff questioned why the dialysis center had not sent the resident directly to the emergency room and did not immediately act on the nephrologist's recommendation or the family's request. The family member expressed frustration and concern over the staff's reluctance to send the resident to the hospital, as did the dialysis center staff, who clarified that they could not send residents to the ER for non-emergent situations and had communicated the nephrologist's recommendation to the facility. The resident was eventually sent to the emergency room, but only after significant delay and repeated requests from the family and dialysis center. Interviews with facility staff, the NP, the medical director, and the attending physician confirmed that the nurses should have contacted the resident's physician to obtain an order for hospital evaluation as requested by the family and the nephrologist. Facility policy required prompt notification of the physician and resident representative in the event of significant changes in condition or the need for hospital transfer, but this was not followed in this case. The delay in consulting the physician and acting on the family's request constituted a failure to follow policy and could have resulted in delayed medical treatment for the resident.