Failure to Immediately Notify Physician of Change in Condition
Penalty
Summary
The facility failed to immediately notify a resident's physician when there was a significant change in the resident's physical condition. Specifically, a nurse observed that a resident with a history of urinary retention and benign prostatic hyperplasia, who had an indwelling catheter, had red-tinged urine and low output during a shift. The nurse documented the finding and intended to notify the oncoming shift, but did not immediately inform the physician. The next shift was notified by a family member about continued issues with the catheter, including clots and dark red urine, at which point the physician was contacted and further interventions were ordered. Interviews with staff confirmed that changes in urine color and output should be promptly reported to the physician, and that it is the nurse's responsibility to ensure timely notification of any change in condition. The facility's policy also requires immediate physician notification for such changes. Documentation and staff statements indicated that the initial nurse did not follow this protocol, resulting in a delay in physician notification regarding the resident's change in condition.