Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify a resident's physician of a significant change in condition, specifically repeated episodes of watery stool. Documentation showed that a resident with multiple complex diagnoses, including cerebral palsy, peripheral vascular disease, seizure disorder, chronic lung disease, and asthma, experienced watery bowel movements on several occasions over a two-week period. Despite this, there was no evidence in the nursing or medical notes that the Medical Director or physician was informed of these changes, as required by facility policy. Interviews with facility staff revealed that Certified Nursing Assistants are responsible for reporting such changes to the nursing staff, who are then expected to assess the resident and notify the physician. However, the Registered Nurse Supervisor could not recall being informed of the resident's condition, and the Medical Director confirmed they were not notified. The facility's policy mandates physician notification for any change in a resident's condition to ensure continuous quality of care, but this process was not followed in this instance.