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 the resident's mental status, as required by facility policy. The resident, an elderly female with a complex medical history including acute kidney failure, chronic kidney disease, recent stroke, C-Diff infection, UTI, and metabolic encephalopathy, was admitted to the facility and experienced a change in mental status during her stay. Staff interviews and record reviews revealed that the resident was only at the facility for three days before being sent to the hospital at the request of her family, who noticed the change in her condition. On the day of the incident, the resident was observed by staff to be alert and oriented, but the change in mental status was not immediately recognized by the staff, many of whom had limited prior experience with the resident. The family member identified the change and requested hospital transfer. The nurse responsible for the resident at the time did not notify the attending physician of the change in condition or the transfer, as confirmed by interviews with facility leadership and the physician. The facility's policy required immediate notification of the physician in the event of a significant change in condition or hospital transfer, but this was not followed. Interviews with the resident's physicians and facility staff confirmed that the physician was not informed of the change in mental status or the hospital transfer. Both the Assistant Director of Nursing and the Administrator acknowledged that the nurse failed to follow the notification policy. The deficiency was identified through interviews, record reviews, and confirmation from the involved parties that the required physician notification did not occur.