Failure to Notify Physician and Dialysis Team of Resident's Change in Condition and Refusal of Treatment
Penalty
Summary
The facility failed to ensure timely and appropriate notification of a resident's physician and dialysis team regarding significant changes in the resident's condition and refusal of treatment. The resident in question had end stage renal disease requiring dialysis, chronic pain managed with opioids, and diabetes, and was noted to have moderately impaired cognition. On multiple occasions, staff observed the resident to be out of sorts, smelling of alcohol, refusing dialysis, and refusing medications, but there was a lack of documentation and communication with the medical team regarding these changes. Specifically, after the resident was noted to smell of alcohol, an order was obtained for a drug and alcohol screen, but the resident refused the test. This refusal was not documented in the medical record, nor was the nurse practitioner or dialysis team notified of the refusal. Additionally, when the resident refused dialysis and medications and exhibited altered consciousness, there was no documentation of nursing assessment or notification to the medical team about the held medications or the resident's ongoing condition. The nephrologist confirmed that neither she nor her staff were informed of the resident's possible intoxication or altered mental status prior to the next dialysis session. Facility policy required immediate notification of physicians for acute problems or significant changes in resident status, with appropriate assessment and documentation. However, the facility did not follow these guidelines, as evidenced by the lack of timely communication and documentation regarding the resident's refusal of treatment, changes in condition, and the holding of medications. This deficiency was identified through interviews, record reviews, and policy examination.