Failure to Notify Provider of Significant Change in Resident Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify the medical provider of a resident’s change in condition as required by facility policy. The facility’s “Change in Condition” policy dated 4/1/25 states that residents, medical providers, and resident representatives are to be informed of changes in the resident’s condition. The resident involved had diagnoses including chronic kidney disease and heart failure and was documented on the MDS as having no cognitive impairment. Review of the clinical record from admission through mid-November showed no prior documentation of tremors, convulsions, seizures, Parkinson’s disease, Parkinsonism, or yelling out. The resident’s care plan identified risk for complications related to high blood pressure, with interventions to observe for signs and symptoms of elevated blood pressure. On a mid-November date, nursing documentation indicated that information was passed from the night nurse that the resident was having Parkinson’s-like tremors with no prior history. The nurse and CNA repeatedly adjusted the resident in bed due to flopping and rapidly flapping legs, and the resident only briefly opened her eyes. The resident was yelling out in pain and received PRN pain medication but could not verbalize the pain location. While in a wheelchair, she arched her back as if having a seizure and snored loudly, taking only a few bites of food before snoring again. A skilled nursing note from that day documented yelling out in pain and marked provider and responsible party notification fields as “not applicable.” Later that day, the resident was transported to the hospital for severe back pain, with documentation of eyes closed, posturing of head, hands, and arms, and leg spasms and jerking, and inability to feed herself due to rigid hands. Vital signs showed oxygen saturation at 92% and 91% on room air, lower than any prior readings since admission, and a temperature flagged as abnormal by the electronic charting system. The clinical record did not show that the medical provider was notified of these changes when they occurred. The Nursing Home Administrator and DON confirmed that the facility failed to notify the medical provider of the change in condition for this resident.
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