Failure to Notify Physician and Representatives of Significant Changes in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative in a timely manner after a significant change and failure to immediately notify a physician and representative when a resident developed tachycardia. One resident had been admitted with a determination by two physicians that the resident was incapable of making all medical decisions. A podiatry consult dated 08/28/2025 documented that the resident refused to be seen by the facility podiatrist, who informed the nursing unit manager and requested that nursing staff call the resident’s representative about the refusal. A nursing progress note later completed by the unit manager on 10/31/2025 documented that the resident refused care on 08/28/2025 by telling staff to stop and leave them alone, but there was no indication that the resident’s representative was notified at the time of the refusal. The corporate DON confirmed that the representative was not notified when the refusal occurred. The second deficiency involved another resident with chronic respiratory failure, a gastrostomy tube, ventilator dependence, seizure disorder, and multiple sclerosis, who was totally dependent on staff for all care. The facility’s policy on physician notification of a change in condition required nursing staff to report changes in condition to the physician and responsible family members and to notify the physician of abnormal vital signs, including a resting pulse rate greater than 100 beats per minute. A respiratory therapist’s note on 12/25/2025 documented that this resident’s heart rate was 120 beats per minute, irregular, and a new onset, and that the attending RN on day shift was notified of the tachycardia. The MAR showed that an LPN administered Metoprolol at 9:00 a.m. the same day and documented a blood pressure of 140/78 with a pulse of 120 beats per minute, but there was no documentation that the physician or the resident’s representative was notified of the abnormal heart rate, and the LPN could not recall being informed of or documenting the elevated pulse.
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