Failure to Obtain Timely Physician Response After Resident Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely physician response and quality treatment and care in accordance with professional standards of practice when the resident experienced a change in condition. The resident was admitted with multiple diagnoses, including urinary tract infection, diabetes, heart failure, and chronic kidney disease. In the early morning, a nursing progress note documented that an SBAR was sent to the resident’s physician at 12:42 AM, reporting the resident was hard to arouse, appeared somnolent, had slept most of the shift, had eaten no dinner, and might be showing signs and symptoms of sepsis or a urinary tract infection, and requested further evaluation and treatment. Later that day, at 3:45 PM, another nursing progress note documented a second SBAR to the physician, reporting congestion, refusal of medications and food throughout the day, and that the resident had been sleeping most of the day, and asked if the physician could see the resident, order labs, or a portable chest X-ray. At 4:10 PM, the nurse documented that the resident was found in bed catatonic and unresponsive when brought to the nurse at 3:20 PM, and the physician was called and approved sending the resident to the ER via emergency transport. There was no documentation that the physician communicated with the facility between the first SBAR at 12:42 AM and the second SBAR at 3:45 PM, and the Administrator later acknowledged the facility had no record of a physician response to the initial SBAR before the resident was sent to the ER.
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