Failure to Notify Physician of Significant Change in Resident Condition
Penalty
Summary
The facility failed to notify the attending physician of a significant change in condition for one resident, as required by facility policy. The policy mandates prompt identification, assessment, intervention, and communication with the resident, family, and healthcare providers when there is a sudden or significant deterioration in a resident's baseline health status. In this case, the clinical record review showed that the resident, who was severely cognitively impaired and had multiple complex diagnoses, experienced an unwitnessed fall with head injury, followed by persistent head and neck pain, increased confusion, and changes in mental status. Despite ongoing documentation of the resident's worsening symptoms—including repeated complaints of pain, increased confusion, refusal of medications and food, and elevated blood glucose—there was no evidence that the attending physician was notified of these changes prior to the resident's transfer to the hospital. While a physician assistant and a certified registered nurse practitioner were involved at various points, and the resident's responsible party was contacted, the attending physician was not informed as required by policy. The resident's condition continued to decline, ultimately resulting in hospital admission for trauma. Interviews with facility leadership confirmed that there was no documentation verifying physician notification before the hospital transfer. The deficiency was cited under state regulations for nursing services and resident care policies, as the facility did not follow its own protocols for managing and communicating significant changes in a resident's condition.