Failure to Timely Notify Physician of Change in Condition and Elevated Blood Pressure
Penalty
Summary
The facility failed to immediately notify the physician of a resident's change in condition, specifically for a resident with a history of hypertension and cerebral infarct. On two consecutive days, the resident was observed by staff and family to be sleepier than usual, which was a deviation from their normal behavior. Despite these observations being reported to licensed nursing staff, there was no timely notification to the physician regarding the resident's altered mental status. On the morning of the second day, the resident's blood pressure was recorded at 153/91 mmHg, which was elevated compared to normal values. The facility's policy required that such changes in condition be reported to the physician within 15 minutes. However, the physician was not notified of the elevated blood pressure at that time. Progress notes indicated that the physician was only made aware of the resident's refusal of medication, not the elevated blood pressure or the change in mental status. Later that day, the resident's condition deteriorated further, with blood pressure rising to 210/92 mmHg and the resident becoming lethargic and unresponsive. The resident was subsequently transferred to a hospital, where a CT scan revealed a significant intracranial hemorrhage. Interviews with staff and review of records confirmed that the physician was not notified in a timely manner about the resident's change in condition, contrary to facility policy and the care plan instructions.