F0684

E

Failure to Document and Communicate Change of Condition and STAT Diagnostic Order

North Hollywood, California Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that a ventilator‑dependent resident with chronic respiratory failure and an anoxic brain injury received care and documentation consistent with professional standards and facility policy during a change of condition. The resident, who required total care and constant supervision and was dependent for activities of daily living, experienced tachycardia and tachypnea on 12/30/2025. A STAT chest x‑ray was ordered by a nurse practitioner (NP) via phone at 6:08 p.m., and a respiratory therapist documented at 6:28 p.m. that the resident had tachycardia and tachypnea. However, there was no corresponding Change of Condition (COC) documentation by the responsible RN that described the signs and symptoms or the events that led to the STAT diagnostic order.

The facility’s Director of Nursing (DON) and RN 1 both confirmed during record review that no COC form or nursing note was completed on that date to explain why the STAT chest x‑ray was ordered. RN 1 stated that tachycardia is a change of condition and that a STAT order is definitely a change of condition, and therefore should have been charted. The DON explained that a COC is any change from a resident’s baseline, such as abnormal vital signs or breathing, and that staff who observe a COC must report it to the primary nurse, who then notifies the charge nurse. The charge nurse is then responsible for assessing the resident, contacting the physician, and completing COC documentation, including documenting physician notification and any ordered care. Because no COC documentation was completed, it was unknown whether the resident’s physician was notified of the tachycardia, tachypnea, or the STAT chest x‑ray ordered by the NP.

The NP’s documentation was also deficient. Although the NP stated that nurse practitioners function under a collaborative agreement with a physician, typically notify the attending physician of COCs and orders, and that physicians co‑sign NP orders, there was no timely progress note by the NP on or immediately after 12/30/2025 explaining the clinical indications for the STAT chest x‑ray or whether the attending physician was notified. A Medical Professional Note was entered six days later, on 1/05/2026, stating that the patient had tachycardia and was placed on backup ventilator settings due to work of breathing, but the note did not clearly specify whether these findings occurred on 12/30/2025 or 1/05/2026, nor did it document physician notification regarding the STAT order. The DON stated that, as a professional standard of practice, NPs should document in their progress notes when they notify the physician about a COC or when they give an order, and that verbal or phone orders should be supported by timely documentation explaining why the order was given. Facility policies on Reporting Changes in Condition and Documentation Principles required timely communication of significant changes to the attending physician and maintenance of a current, detailed health record consistent with good medical and professional practice, which did not occur in this case.