Failure to Notify Physician of Significant Changes in Condition
Penalty
Summary
The facility failed to ensure timely physician notification of significant changes in condition for three residents. For one resident with multiple diagnoses including a femur fracture, diabetes, and Crohn's Disease, a 14.9% weight loss occurred over 27 days, but there was no documentation that the physician was informed of this significant change. Another resident with a femur fracture, B-12 deficiency anemia, and hyperlipidemia experienced an 11.66% weight loss over 84 days, again without evidence of physician notification. Both residents were identified as being at risk for nutritional deficits and had care plans indicating that untreated weight variances should not occur. A third resident with mild cognitive impairment, sepsis, and Parkinson's disease exhibited a notable decrease in blood pressure and increases in temperature and heart rate, but there was no documentation that the physician or DON were notified of these changes. The resident was later found pulseless and passed away, with conflicting documentation regarding the frequency and nature of monitoring prior to death. Interviews with facility staff confirmed the lack of physician notification and absence of required documentation regarding these significant changes in condition.