Failure to Notify Physician of Resident’s Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of a resident’s change in condition related to new left knee symptoms and episodes of respiratory distress. The resident was admitted with multiple diagnoses including hypertension, prediabetes, atherosclerosis of the aorta, a right distal humerus fracture, and a frontal bone fracture from a fall, and had bilateral lower leg 2+ edema with dry, cool skin on admission. A progress note documented that the resident was seen at 11 p.m. with left knee swelling and weakness, and the knee was bruised, warm to touch, and mildly tender. During interview, the DON stated these were new signs and symptoms that should have been reported to the physician, but there was no indication that the physician was notified. The facility also failed to notify the physician when the same resident experienced respiratory distress. A progress note indicated that at 2:30 a.m. the resident had shortness of breath and difficulty breathing, described by the resident as an asthma attack, and at 3:26 a.m. the resident was observed gasping for air with a respiratory rate of 24 breaths per minute, with the episode lasting less than five seconds. The LVN who assessed the resident stated he did not recall notifying the physician, explaining that the resident attributed the symptoms to asthma, refused hospital transfer, and that vital signs remained normal for the rest of the shift, and he was unsure if the resident had an asthma diagnosis. Review of the order summary showed an instruction to call the physician if respiratory rate was greater than 20, and the DON stated the resident’s respiratory symptoms and respiratory rate of 24 should have been reported. The facility’s change of condition policy required assessment, documentation, and appropriate follow-through to the physician for altered vital signs and new significant edema, among other changes, which was not followed in this case.
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