Failure to Timely Notify Physician and Family After Resident Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to provide timely physician and family notification when a resident experienced a change in condition. The resident had moderately impaired cognition, diabetes mellitus, partial paralysis, and non-traumatic brain dysfunction, and required varying levels of assistance with activities of daily living. Her care plan directed staff to involve her family with decisions and medical updates. On the day of the incident, an LPN attempted to wake the resident while she was seated in her wheelchair at the dining room table; the resident was lethargic and required multiple taps or grabs of her arm to respond. The LPN moved the resident to a sunnier area and asked a CMA to obtain vital signs, which showed a temperature of 100.4°F. The LPN instructed the CMA to administer Tylenol, but the resident refused the medication twice, pulling her head back and saying no. The LPN then instructed a CNA to return the resident to her room. A nursing progress note documented at 12:05 PM that the resident was semi-responsive, responding only to touch and voice, and had a temperature of 100.4°F with refusal of Tylenol. Staff interviews, including RNs and LPNs, confirmed that a temperature of 100.4°F in a typically responsive resident who becomes lethargic and requires loud voice or touch to respond constitutes a change in condition that requires provider notification and documentation on an electronic change in condition form and in progress notes. The involved LPN acknowledged that the event was a change in condition and that the change-in-condition form should have been completed at that time, but she went to lunch at 12:19 PM without notifying another nurse and did not contact the resident’s brother and provider until after returning from lunch at 1:25 PM. An eINTERACT Change in Condition Evaluation later documented family and provider notification at 1:00 PM. The facility’s Notification of Changes policy required informing the resident, consulting with the physician, and/or notifying the family or legal representative when there is a significant change in the resident’s physical, mental, or psychosocial condition, such as deterioration in health or status, which did not occur in a timely manner in this case.
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