Failure to Notify NP of Resident’s Elevated Heart Rate
Penalty
Summary
The deficiency involves the facility’s failure to follow its policy requiring notification of the attending physician extender and resident representative when there is a significant change in a resident’s condition, including unstable vital signs such as pulse. The facility’s policy titled "Notification of a Change in a Resident's Status" specifies that the physician/NP and responsible party must be notified for significant changes in or unstable vital signs. Resident #5, admitted with diagnoses including acute respiratory failure, depression, urinary tract infection, a stage 3 pressure ulcer of the left buttock, and infection of the skin and subcutaneous tissue, had a Quarterly MDS indicating moderately intact cognition with a BIMs score of 8. During a morning medication pass, the LPN observed that Resident #5’s heart rate was elevated between 130–137 beats per minute and identified this as a new change in condition. The LPN reported that the elevated heart rate persisted throughout her shift. She asked the resident and the resident’s husband if they wanted to go to the hospital, and both declined. Despite recognizing that facility practice and policy require notifying the physician or NP of a change in condition even when a resident refuses transfer, the LPN did not notify the NP of the elevated heart rate. The NP later stated he expects to be notified of any change from baseline and confirmed he had not been informed of this event. The DON also confirmed that an increased heart rate is a change in condition and that the NP should have been notified, establishing that the required notification did not occur for this resident’s elevated heart rate.
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