Failure to Notify Resident Representative and Physician of Change in Condition and Treatment
Penalty
Summary
The facility failed to ensure that a resident's representative and physician were notified of changes in the resident's condition. Specifically, for a resident with multiple complex diagnoses including severe cognitive impairment, Alzheimer's disease, diabetes, and a history of falls and pressure ulcers, there was a documented decline in appetite, muscle tremors, and an elevated heart rate. The on-call physician was notified and ordered an EKG, x-ray, and laboratory tests. The x-ray was completed, and the family was later updated on the new orders and the resident's refusal of labs, as well as pending consults and potential IV fluid orders. However, there was no documentation that the resident's representative was notified of the x-ray results. Additionally, although a verbal order was given to start IV fluids and the resident agreed to the treatment, there was no documentation that the IV fluids were administered or that the physician was notified of the failure to administer them. The unit manager LPN confirmed the lack of documentation regarding both the unsuccessful IV attempt and physician notification. Facility policy required prompt notification of the attending physician for changes in treatment needs, but this was not followed in this instance.