Failure to Promptly Notify Physician of Resident Change in Condition
Penalty
Summary
Facility staff failed to immediately assess and notify the physician when a resident experienced a significant change in condition, including severe weakness, inability to eat, and inability to speak during a morning shift. The resident, who had a history of type 2 diabetes, hypertensive heart disease, anxiety disorder, schizophrenia, COPD, and hypertension, was noted to have intact cognitive skills prior to the incident and was partially dependent on staff for mobility and transfers. On the morning in question, the resident was found unresponsive to verbal communication and refused breakfast, with initial vital signs showing a heart rate of 59 and oxygen saturation of 94%. Despite these changes, the initial response by one of the LVNs was to allow the resident to rest, believing more sleep was needed, and did not immediately recognize the situation as a change of condition. It was only after further decline, including a heart rate dropping to 40 and oxygen saturation to 89% on nasal cannula, that the charge nurse was notified and the physician was contacted. The physician then ordered the resident to be transferred to an acute care hospital via 911 for further evaluation and treatment. Interviews with staff and review of facility policies confirmed that the delay in assessment and notification was contrary to facility procedures, which require prompt physician notification for significant changes in a resident's condition. The Director of Nursing acknowledged that such delays pose a resident safety risk. The deficiency was identified based on the failure to promptly assess and notify the physician, resulting in further decline of the resident and the need for emergency transfer.
Plan Of Correction
F0580 Notify of Changes (Injury / Decline / Room, etc.) CFR(s): 483.10(g)(14)(i)-(iv)(15) On 12/11/25, resident 3 was transferred to the General Acute Care Hospital (GACH) via 911. On 12/21/25, resident 3 was readmitted to the facility and is currently safe and comfortable. To identify other residents with the potential to be affected, the DON reviewed any changes of condition for the last 30 days and no other residents were found to be affected by this deficient practice. On 12/29/25, the DON in-serviced licensed nurses regarding the facility's policy and procedure titled "Change in a Resident's Condition or Status," with emphasis on the nurse supervisor/charge nurse notifying the resident's Attending Physician or On-Call Physician when there has been a significant change in the resident's physical, emotional, or mental condition. On 12/29/25, the DON also in-serviced licensed nurses regarding the facility's policy and procedure titled "Vital Signs," with emphasis on vital signs being indicators of health status. Licensed nurses are responsible for knowing the usual range of a resident's vital signs, analyzing and interpreting routine vital signs, and notifying the physician of abnormal findings. To ensure that the systems in place are sustained and maintained, the DON or designee will conduct a random audit of five residents weekly for twelve (12) consecutive weeks. These residents will be reviewed to ensure that if there was any change of condition that has been identified, they were properly evaluated and communicated to the appropriate people. The DON will report any negative findings to the Quarterly Quality Assurance and Assessment (QA&A) Committee for review and recommendations for the next 3 months. Corrective Action Completion Date: 12/31/2025