Failure to Notify Physician and Document Change in Condition and Transfer
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician of a significant change in condition and of the decision to transfer the resident from the facility. Record review for one resident who later died showed progress notes documenting a change in code status from full code to Do Not Resuscitate (DNR) and a subsequent note that EMS arrived to pronounce the resident deceased. However, there was no documentation of a change in condition assessment, no progress note describing the events leading up to EMS involvement, and no medical order indicating that the physician had ordered the resident to be sent to the hospital. During an interview, the DON stated that nursing staff are expected to immediately notify the physician after assessing a resident with a change or decline in health status, and that if the physician decides to send the resident to the hospital, an order should be entered and all actions documented in the medical record. When reviewing the resident’s record, the DON confirmed EMS had been called but could not identify who called and noted that the nurse should have documented this. The DON also confirmed there was no medical order to send the resident out and no change in condition documentation, and stated that the nurse should have completed a late entry if the situation had been chaotic. The DON acknowledged the concern that there was no documentation indicating that nursing staff notified the physician of the resident’s change in condition or the decision to transfer.
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