Failure to Timely Report and Document Change of Condition
Penalty
Summary
A deficiency occurred when the facility failed to provide services according to standards of clinical practice by not reporting and documenting a resident's change of condition in a timely manner. The resident, who had a complex medical history including acute embolism and thrombosis of the femoral vein, acute kidney failure, obstructive and reflux uropathy, hydronephrosis, and urinary retention, was observed by physical therapy staff to have increased pallor, lethargy, clammy skin, and severe abdominal pain. The physical therapy note indicated that both the medication nurse and charge nurse were made aware of these symptoms at 12:30 P.M., but there was no corresponding nursing documentation of the change in condition at that time. Interviews with nursing staff revealed that although the charge nurse and medication nurse were notified and assessed the resident, they did not document their assessments or the notifications to the nurse practitioner (NP) in the electronic medical record (EMR) in a timely manner. The first nursing note regarding the change of condition was not entered until 3:12 P.M., nearly three hours after the initial observation. Staff reported that they attempted to contact the NP multiple times via text and phone, but these attempts and the lack of response were not documented as required by facility policy. The medication nurse acknowledged that she should have documented her assessment and communication efforts but did not do so due to being busy. Facility policy required timely notification and documentation of significant changes in a resident's condition, including communication with the attending physician or NP and the resident's family. The lack of timely documentation and notification was confirmed by the Director of Nursing, who stated that if actions are not documented, they cannot be proven to have occurred. The resident was ultimately transferred to the hospital later that evening after persistent symptoms and at the family's request.