Failure to Notify Physician of Change in Resident Condition
Penalty
Summary
The facility failed to notify a resident's physician of a significant change in condition as required by facility policy. The resident in question had multiple diagnoses, including dysphagia, anxiety, respiratory failure, and required a feeding tube. A physician's order specified oxygen administration at two liters per minute via nasal cannula every shift. On one occasion, staff observed the resident with a dangerously low oxygen saturation of 49% while on supplemental oxygen, necessitating the use of a rebreather mask at ten liters per minute. Later, the resident experienced choking on saliva, required suctioning and a breathing treatment, and developed a fever of 101.1°F. The oxygen flow was increased to five liters per minute, exceeding the physician's order, to maintain oxygen saturation at 90%. Despite these significant changes in the resident's condition, there was no evidence that the physician or any practitioner was notified or assessed the resident until the following day. Staff interviews confirmed that the physician should have been notified at the time the change in condition was identified, but documentation and interviews revealed this did not occur. The deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) for nursing services.