Failure to Notify Physician of Significant Change in Condition
Penalty
Summary
The facility failed to notify a resident's physician when there was a significant change in the resident's condition, specifically when the resident experienced an episode of slurred speech. On the morning of 10/18/25, a nurse documented that the resident had a brief episode of slurred speech during assessment, which resolved with the resident returning to baseline. Vital signs were within normal limits, and no facial droop or extremity weakness was observed. However, there was no documentation that the physician was notified of this episode, despite facility policy and professional guidelines requiring immediate physician notification for new or unexpected findings such as slurred speech. The resident had a medical history including cerebral infarction, type 2 diabetes mellitus, and hypertension, and was cognitively intact according to recent assessments. Staff interviews revealed that the nurse who assessed the resident on 10/18/25 notified the ADON of the change in condition, but did not notify the physician. The ADON stated that she instructed the nurse to notify the physician, but this was not documented, and the DON confirmed that physician notification should have occurred. The deficiency was further highlighted when, four days later, the resident experienced another episode of slurred speech, at which point the physician was notified and the resident was transferred to the hospital. Facility records and staff interviews confirmed that the physician was not notified after the initial episode of slurred speech, and there was no documentation to support that the resident's intermittent slurred speech was considered baseline. The facility's policy required physician notification for such changes, and all interviewed staff agreed that this should have occurred. The lack of physician notification after the initial episode constituted a failure to follow both professional standards and facility policy regarding change in condition reporting.