F0580

D

Failure to Notify Provider of Acute Change in Condition Related to ICD Shocks

Dayton, Ohio Survey Completed on 02-24-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to notify a physician or non-physician provider when a resident experienced an acute change in condition. Resident #52, admitted with diagnoses including cerebral infarction, COPD, and acute respiratory failure with hypoxia, had intact cognition per a recent MDS with a BIMS score of 15. On 01/31/26, between 11:00 A.M. and 10:55 P.M., there was no documented evidence that the physician or on-call provider was contacted when the resident had an acute change in condition around 1:00 P.M. Later that evening at 10:56 P.M., an RN documented that the resident complained of a shocking feeling in his chest; assessment showed a pacemaker with heart rates of 64 and then 69 bpm, and the on-call provider was contacted but did not answer, with the nurse awaiting a return call.

In the early hours of 02/01/26 at 12:55 A.M., an LPN documented that the resident complained his ICD had been shocking him for the last four hours, with vital signs including BP 94/59 mmHg, HR 92, RR 22, and O2 sat 96%. The resident requested transfer to the emergency room due to fear from the shocks, and the on-call provider then agreed to send him to the hospital; EMS later recorded elevated heart rates up to 225 and documented that the resident reported 12–15 ICD shocks in the prior three hours and was in A-fib with RVR. Hospital records showed the resident, with significant cardiac history including CAD, ischemic cardiomyopathy with EF 20–25%, prior CABG, and ICD placement, required cardiology consultation, initiation of amiodarone, and ICU admission. In an interview, the resident stated he had been shocked and initially was not sent out despite significant discomfort. An LPN who worked the 7:00 A.M. to 8:00 P.M. shift on 01/31/26 reported the resident was screaming and saying a man or the bed was shocking him; she suspected a UTI, unplugged and checked the bed, took vital signs but did not document them, did not know he had an ICD, and only placed a written note in the provider binder without calling the provider about the acute change. The DON confirmed staff should document and notify the provider for acute changes and verified the provider was not notified of the change in condition on 01/31/26, contrary to the facility’s Change in Condition policy requiring immediate physician notification for significant changes.