Failure to Notify Physician of Significant Neurological Change and Unresponsiveness
Penalty
Summary
The deficiency involves the facility’s failure to consult a resident’s physician when there was a significant change in the resident’s physical and neurological status. The resident was an older female with multiple serious diagnoses, including dementia, Stage 4 chronic kidney disease, atrial fibrillation, seizure disorder related to prior brain surgery, chronic respiratory failure with hypoxia, multiple fractures, chronic pain, and long-term anticoagulant use. Her care plan included detailed seizure precautions and post‑seizure assessment and documentation requirements, as well as instructions to monitor and immediately notify the physician of signs and symptoms such as altered level of consciousness, changes in mental status, and neurological changes. On the night in question, the DON was working the floor when CNAs called her to the resident’s room at approximately 4:30 a.m. because the resident was unresponsive. The DON documented that the resident was unresponsive, with vital signs within normal limits, no distress, and breathing that was not labored, and that the resident appeared to be resting comfortably. The DON stated in interviews that the resident was not acting right, was unresponsive but still breathing, and only opened her eyes slightly in response to a sternal rub, with no other response to questions. About 20 minutes later, the DON was called back and found blood in the resident’s mouth; after cleaning, she determined the resident had bitten her bottom lip. The DON documented that the lip and mouth were cleansed and no further bleeding was noted, and she instructed CNAs to increase monitoring and report any changes. The DON did not notify the physician at either time, later acknowledging in interviews that she "absolutely should have called the doctor" but did not because it was early in the morning and she did not think the situation was serious. When the day shift began, LVN staff received report that the resident had a "bad night" and that the DON thought the resident might be septic, though vital signs were normal. LVN staff assessed the resident around the start of the shift and found vital signs to be fine and the resident more alert at that time. Later that morning, LVN staff observed that the resident was less responsive and appeared more worrisome, and CNAs were instructed to prepare her for transfer to the hospital. During peri care, the resident had seizure‑like activity lasting about 30 seconds, after which she was unresponsive with shallow, labored respirations and did not respond to tactile or painful stimuli. EMS was called and the resident was transported to the hospital. The resident’s physician stated in interview that he would have wanted to be notified if a resident was found unresponsive but still breathing and not talking after a sternal rub, or if a resident was unresponsive and had bitten her lip, and that if he had known of the unresponsiveness that morning, he would have had her sent to the hospital immediately. The facility’s own policy on acute condition changes required nursing staff to contact the physician based on the urgency of the situation, including for significant changes in neurological status and level of consciousness, which did not occur in this case.
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