F0684

G

Failure to Notify Practitioner and Timely Transfer for Acute Change in Condition

Waterford, Michigan Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to notify a practitioner of an acute change in condition and to ensure timely transfer to the ER for a resident who was newly admitted with diagnoses including heart failure, edema, chronic kidney disease, atrial fibrillation, high blood pressure, and muscle wasting/atrophy. Shortly after admission, the resident developed extreme abdominal pain with nausea and vomiting. On the morning in question, vital signs documented at 9:27 AM by a nurse showed a blood pressure of 178/105, heart rate of 125 with an irregular rhythm, and a temperature of 94.8°F. The nurse later stated they were “pretty sure” they reached out to the NP or PA, but the clinical record contained no indication that the MD, NP, or PA had been notified of these abnormal vital signs.

In the afternoon, another nurse documented at 2:38 PM a blood pressure of 101/86, heart rate of 133 with an irregular rhythm, and temperature of 96.6°F, with a pain score of 7/10 at 2:44 PM. A progress note at 2:39 PM indicated the PA assessed the resident at bedside with the daughters present, noting abdominal pain and 10 cc of green emesis, and ordered an abdominal X-ray and stat labs for abdominal pain and nausea. The PA later reported the resident was in “poor condition,” lying flat in bed with a damp towel on the chest, complaining of left upper quadrant abdominal pain, and stated they suspected sepsis, ordering the X-ray and stat labs but choosing to wait for results before sending the resident to the ER. The PA also stated they had not been made aware of, nor reviewed, the earlier abnormal vital signs from that morning.

That evening, a nurse documented that at approximately 6:30 PM the resident was observed hyperventilating, with vital signs of 154/78, heart rate 120 bpm, and respiratory rate 32/min. While the nurse was on the phone with the on-call prescriber to report “sepsis like symptoms,” another nurse received a call from the lab reporting a critically high WBC of 31,700, which was communicated to the provider, who then ordered transfer to the ER for sepsis. The supervising physician later stated that the morning vital signs should have been reported and that, had they been contacted, they might have started fluids and probably would have sent the resident to the ER. The DON agreed that the morning blood pressure, heart rate, and temperature were a concern and should have been reported, and acknowledged that the PA waited to see if ordered interventions would work before sending the resident out. The facility’s policies on Notification of Change and Transfer and Discharge require practitioner notification for significant changes in status and transfer when the resident’s needs cannot be met in the facility. The resident’s death certificate listed sepsis and pneumatosis intestine as the causes of death.