Failure to Notify Physician After Resident Syncopal Episode
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of a resident’s change in condition following a syncopal episode. The resident had multiple significant diagnoses, including pneumonia, acute respiratory failure, chronic heart failure, chronic kidney disease, atrial fibrillation, and syncope, and the admission MDS indicated no cognitive deficits. On 4/3/26, a trained medication assistant (TMA-A) assisted the resident to stand with a gait belt; upon rising, the resident leaned forward, went limp, and was lowered back into a recliner. The resident then opened his eyes and spoke. TMA-A immediately called for assistance via walkie talkie, and LPN-A, LPN-B, and the RN nurse manager (RN-NM) responded. A health status note later documented that the resident had passed out for a few seconds during the transfer and that a nurse was notified and evaluated the resident. Despite this documented change in condition, there was no indication in the resident’s record that the physician was notified on the day of the event. LPN-A reported that when she entered the room the resident was alert, and she left because it was the end of her shift, stating that a provider should be updated any time a resident has a change in condition. LPN-B stated she responded to the call, found the resident alert and following commands, but did not check vital signs, did not notify the provider, and did not complete a nursing note, explaining there was a lot going on that shift; she also acknowledged that a note and provider notification should occur with a change in condition. RN-NM stated that when she entered, the resident was alert and LPN-B was obtaining vital signs, and confirmed there was no nurse’s note or provider notification documented, despite the resident not having had such an episode previously at the facility. The DON stated the provider should have been notified the day of the event because it was a significant change from baseline, and the physician later reported learning of the dizziness episode days afterward during routine rounds, stating she would have wanted immediate notification. The facility’s Change of Condition policy instructed staff to notify the physician in the event of a status change.
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