Failure to Notify Physician and Family of Resident's Increased Pain and Bruising
Penalty
Summary
The facility failed to ensure timely notification of a physician and a resident's representative regarding increased right hip pain and significant bruising in a resident with severe cognitive impairment and multiple comorbidities, including atrial fibrillation and use of anticoagulant medication. The resident, who was dependent for transfers and had a history of falls, began experiencing right hip pain and was observed with bruising of unknown origin. Documentation shows that pain and bruising were noted and treated with Tylenol, but there was a delay in reporting these changes to the physician and family. Staff interviews revealed that bruising was first identified and reported among staff, but not immediately communicated to the physician or family, and the size and extent of the bruising were not consistently documented at the time of discovery. Progress notes and staff interviews indicate that the resident's pain increased over several days, with pain scores reaching as high as eight or nine out of ten, and the bruising expanded in size and severity. Despite these changes, the physician was not notified until after the resident was sent to the emergency room at the request of the family, who was also not informed of the situation until the evening the resident was transferred. The medical director confirmed that he was not made aware of the bruising or pain until a follow-up visit days later, and the family expressed concern that they would have requested medical evaluation sooner had they been notified earlier. Facility policy required staff to notify the physician and family of unexplained bruising or changes in condition, especially for residents on anticoagulants. However, staff interviews and documentation review confirmed that these notifications did not occur promptly. The delay in communication and incomplete documentation of the resident's condition led to a deficiency in ensuring that significant changes in the resident's health status were reported as required.