Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to ensure timely physician notification for a significant change in condition for one of three sampled residents. The resident, who had multiple complex diagnoses including acute and chronic respiratory failure, COPD, congestive heart failure, acute pulmonary edema, pleural effusion, type 2 diabetes, hypertension, end stage renal disease, and a history of renal transplant, was readmitted to the facility from a hospital stay. Upon readmission, assessments indicated the resident was alert, oriented, and able to make decisions independently. On two separate occasions, nursing progress notes documented that the resident was alert but experiencing new onset confusion following dialysis. Despite this change in mental status, there was no documentation that the resident's physician was notified, nor was there evidence of a comprehensive nursing assessment or monitoring related to the confusion. The facility's care plan for the resident specifically required monitoring for changes such as altered mentation and prompt reporting to the physician, but these interventions were not carried out as documented. Interviews with the attending physician and a registered nurse confirmed that the new onset confusion represented a significant change in condition that warranted immediate physician notification and further assessment. The physician stated that, had he been notified, he would have sent the resident to the emergency room for evaluation. Review of facility policy indicated that such changes required physician notification, assessment, documentation, and ongoing monitoring, none of which were completed or documented in this case.