Delayed Physician Notification and Neglect of Change in Condition
Penalty
Summary
The facility failed to protect a resident from neglect by not promptly notifying the physician of a significant change in condition. The resident, who had a history of cellulitis and peripheral venous insufficiency, was admitted with minimal cognitive impairment. On the day of the incident, the resident exhibited a resting heart rate of 117 bpm, was shaking, and complained of being cold. Later, the resident developed an elevated temperature of 100.2°F, which progressed to a fever of 103.6°F and then 104.6°F, along with an altered level of consciousness and decreased oxygen saturation. Despite these symptoms, the physician was not notified until several hours after the initial signs of deterioration were observed. Multiple staff interviews confirmed that the resident's change in condition, including worsening redness in the leg and the development of a high fever, was recognized during the morning shift. However, the assigned nurse did not appear concerned and did not escalate the situation or notify the physician in a timely manner. The Director of Staff Development and the Director of Nursing both acknowledged that a fever is considered a change in condition that requires immediate physician notification, and that the delay in reporting constituted neglect. Documentation of the resident's symptoms, particularly the redness in the leg, was also lacking in the medical record. The facility's own policies require prompt notification of the physician and documentation of significant changes in a resident's condition. In this case, the delay in physician notification and inadequate documentation resulted in the resident experiencing delays in care, ultimately requiring hospitalization for fever, altered mental status, and sepsis. Staff interviews and record reviews confirmed that the facility did not follow its protocols, leading to the identified deficiency.