Failure to Notify Physician of Resident’s Change in Condition
Penalty
Summary
The facility failed to notify a physician of a resident’s change in condition as required by its policy. A resident with diagnoses including Alzheimer’s disease and memory deficit following cerebral infarction, who had impaired cognition with a BIMS score of 9 and required supervision for toileting, bathing, and dressing, was documented in a quarterly MDS as frequently incontinent of bladder and bowel with no skin issues. On a later date at 1:20 P.M., an RN documented that the resident was not acting like herself, was not eating, getting up, or using the restroom, and contacted the resident’s daughter, offering to send the resident to the emergency room; the daughter declined at that time. There was no evidence in the medical record that the physician was notified of this change in condition, and the resident was subsequently transferred to the emergency room at 2:26 P.M. without physician notification. The Regional Nurse confirmed during interview that the physician was not notified, despite facility policy stating that a significant change in a resident’s physical, mental, or psychosocial status requires immediate physician notification. This deficiency was cited for one of three residents reviewed for change in condition, with a facility census of 81, and was investigated under Complaint Number 2731910.
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