Failure to Timely Notify Physician of Significant Change in Condition
Penalty
Summary
The facility failed to notify a physician in a timely manner regarding a significant change in condition for a resident who developed swelling and discoloration of the left fourth and fifth fingers. The resident, who had diagnoses including Alzheimer's disease, schizophrenia, and Parkinson's disease, was severely cognitively impaired and dependent on staff for daily activities. Documentation showed that staff observed the swelling and discoloration, and initial attempts were made to contact the resident's physician, but there was no immediate response. Follow-up calls and texts were made, but the physician did not respond until approximately 13 hours after the initial observation. Facility policy required staff to contact the medical director if the primary physician could not be reached within 30 minutes, but this protocol was not followed. Interviews with nursing staff and the DON confirmed that the medical director was not contacted as required, resulting in a delay in obtaining medical orders for the resident's condition. The facility's job descriptions and policies emphasized timely physician notification and the use of alternate physicians when the primary was unavailable, but these procedures were not adhered to in this instance.