F0684

D

Failure to Notify Physician and Monitor Resident After Significant Change in Condition

La Grange Park, Illinois Survey Completed on 01-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to recognize and respond appropriately to a significant change in condition and to notify the physician as required for a resident with complex medical issues. The resident had diagnoses including alcoholic cirrhosis of the liver with ascites, alcohol abuse, and hepatic encephalopathy. On one afternoon, the resident’s blood pressure was documented at 73/43, which the attending physician later stated was very low and should have been reported. The day/PM shift RN reported that the resident remained in bed, alert but weak, and acknowledged that she did not notify the physician of the low blood pressure, even though the physician had seen the resident earlier that day and the blood pressure was significantly low. The RN also stated that she did not recheck the resident’s vital signs during the PM shift.

Later that night, the night shift RN found the resident in bed, lethargic and in respiratory distress, with vital signs showing blood pressure of 69/33 and oxygen saturation of 81%. The nurse initiated oxygen at 4 L/min via nasal cannula, after which the oxygen saturation increased to the mid-90s, and 911 was called to send the resident to the hospital. The resident was noted to be a full code. The day/PM shift RN also reported that the resident refused bedtime medications and that she did not notify the physician of this refusal. The physician and the Assistant DON both stated that significant changes, such as low blood pressure and refusal of medications, should be relayed to the physician, and facility policy on notification for change of condition requires immediate consultation with the physician when there is a significant change in the resident’s status.