Failure to Immediately Notify Physician and Family of Acute Neurological Change
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify the resident’s responsible party and to update the physician timely when there was a significant change in condition for one resident who was later hospitalized with an acute stroke. The facility’s policy on change in condition, revised in April 2025, required the nurse to use clinical judgment to contact the physician based on urgency and to notify the resident representative of the change. The resident’s face sheet listed two emergency contacts. A progress note documented that at 5:30 AM on 01/04/2026 a change in condition was identified, the on‑call physician was notified, and instructions were given to monitor the resident and call back if the condition did not clear or worsened within 30 minutes. There was no documentation that the responsible party was notified at that time, nor that the physician was called back within 30 minutes as instructed. Later documentation on the same date at 10:11 AM by an RN showed the resident had acute neurological changes, including facial droop, slurred speech, left arm flaccidity, and visual problems. The note indicated the spouse arrived at 8:00 AM and was notified of the change in condition, and that the physician was notified that the family was declining transfer to the hospital, but it did not document immediate notification of either responsible party when the change was first identified. The note also recorded that the second emergency contact arrived at 9:00 AM and agreed to hospital transfer. An emergency room note from a local hospital at 9:40 AM confirmed an acute stroke. A CNA reported observing the resident at 6:00 AM with leaning to one side and inability to focus gaze and stated they summoned the RN, who assessed the resident at 6:10 AM. In interviews, the RN acknowledged that new onset arm weakness and visual problems would be a critical situation warranting physician and family notification and could not recall why the family was not called, while the Assistant DON confirmed that acute neurological changes should be a priority and that documentation did not show immediate family notification or that the physician was contacted again within 30 minutes as previously directed. The survey cited WAC 388-97-0320(1)(b-d).
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.