F0684

D

Failure to Notify Physician of Resident’s Significant Change in Condition

Sainte Genevieve, Missouri Survey Completed on 12-30-2025

Penalty

No penalty information released

Summary

Facility nursing staff failed to notify the physician in a timely manner when a resident experienced a significant change in condition that ultimately resulted in hospitalization. The facility’s policy on Change in Resident’s Condition or Status, revised 02/2021, required nurses to notify the attending or on-call physician when there was a significant change in a resident’s physical, emotional, or mental condition that was not self-limiting and affected more than one area of health status. Despite this policy, there was no documentation that the physician or on-call physician was notified on the days when the resident’s condition notably declined.

The resident involved was cognitively intact per the 12/09/25 Quarterly MDS and required partial to moderate assistance with ADLs, including ambulation and transfers, with only meal setup assistance for eating and partial assistance with toileting. The resident’s diagnoses included coronary artery disease, anemia, cancer, hypertension, orthostatic hypotension, peripheral arterial disease, diabetes with polyneuropathy, depression, and dysphagia. The care plan dated 12/10/25 indicated the resident required substantial assistance with ambulation using a wheeled walker, partial assistance with tray setup, and partial assistance with toileting, with occasional bowel and bladder incontinence.

Progress notes documented a clear decline beginning on 12/13/25, when the resident, previously able to feed self and bear weight, became alert only to self, generally confused, unable to comprehend how to feed self or cut food, stared blankly at food or others eating, was no longer bearing weight and required a Hoyer lift for transfers, was incontinent of bowel and bladder with dark amber, strong-smelling urine, and had pale skin color. On 12/14/25, the resident was described as lethargic, remained in bed with eyes closed, responded only to painful stimuli, was not eating or drinking, had a temperature of 99.7, and was unable to swallow medications, which were held. On the morning of 12/15/25, the resident was noted to be unresponsive and was sent to the emergency room after a new order was received. Interviews with an LPN, the PCP, and the DON confirmed that no physician notification occurred regarding the changes on 12/13/25 or 12/14/25, and all stated they would have expected physician notification based on the documented changes in the resident’s condition.