Failure to Notify Physician of Resident's Increased Agitation
Penalty
Summary
The facility failed to ensure timely physician notification regarding a resident's increased agitation. The resident, who had dementia with behavioral disturbance and a history of falls, was admitted following a recent hospitalization for a fall and was identified as a high fall risk. Nursing documentation showed that the resident exhibited increased agitation, restlessness, and combative behavior during the night shift, including refusing medications and requiring constant redirection. Although the physician was notified of agitation on the day of admission and a PRN Trazodone order was obtained, there was no evidence that the physician was notified of the further increase in agitation and combative behavior observed during the early morning hours of the following day. Facility policy required that the physician, resident, and family/legal representative be informed of changes in condition. Interviews with staff and the physician confirmed that the physician was not notified of the resident's increased agitation on the morning in question, despite expectations and policy. The lack of timely notification occurred prior to an unwitnessed fall, after which the resident was found on the floor with a head injury and transferred to the hospital.