Failure to Notify Physician of Resident’s Significant Change in Condition Leading to Hospitalization for Sepsis
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician of a resident’s significant change in condition despite multiple abnormal findings and behavioral changes. The resident had intact cognition, was care planned for potential infection related to urinary incontinence, and was described as alert, oriented, and independent in decision-making. Over several days, progress notes documented new hallucinations, delusions, crying, and verbal outbursts, including statements about murdering her babies and fears about her babies being taken away. The IDT discussed these behaviors and noted hallucinations. Concurrently, the resident reported vomiting all night, severe pain, and feeling unable to move. Vital signs showed repeated fevers, including temperatures over 101°F and up to 103.2°F, along with tachycardia over 100 bpm. The resident also experienced incontinent diarrhea, generalized pain, fatigue, refusal of medications, and poor oral intake. Despite these documented changes—abnormal vital signs, new behavioral and neurological symptoms, worsening pain, and functional decline—there was no evidence that staff notified the attending physician of the change in condition, even though the care plan directed staff to update the provider as needed and facility policy required provider notification for significant changes and abnormal findings. The IDT noted the resident’s fevers and behaviors and planned to assess and contact the provider “if necessary,” but the physician later confirmed that staff had not contacted her when the resident developed a fever and other symptoms. The resident was eventually noted to be shivering, pale with a grey hue, with dark circles under her eyes, reporting pain all over and not feeling well, at which point an ambulance was called and she was sent to the ED, where she was diagnosed with sepsis due to E. coli with acute organ dysfunction, septic shock, UTI secondary to an obstructing ureteral stone, and acute kidney injury. The physician and another MD interviewed both stated that they had not been notified of the change in condition and that they should have been contacted when the resident developed a fever.
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