Failure to Notify Physicians of Resident Changes in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify physicians of residents’ changes in condition in a timely manner, as required by physician orders, care plans, and facility policy. For one resident with centrilobular emphysema, COPD, and essential hypertension who used continuous oxygen at three liters via nasal cannula, the care plan directed staff to monitor for and report signs of respiratory distress to the physician. On one occasion, the resident experienced trouble breathing during the night and initially refused transfer to the hospital. The DON recalled this event and stated that the resident’s daughter later convinced the resident to go to the hospital that morning. However, the medical record contained no documentation of vital signs, assessments, or any notification to the physician regarding the change in respiratory status or the subsequent hospitalization, and the DON confirmed the assigned LPN did not document the change in condition or physician notification. For a second resident admitted with diagnoses including disruption of an external surgical wound, infection following a procedure, combined systolic and diastolic CHF, type 2 diabetes with polyneuropathy, and chronic kidney disease, the care plan required monitoring and reporting to the physician of significant weight changes and changes in lung sounds, edema, shortness of breath, vital signs, and weight. A physician order directed staff to notify the physician of a weight gain of two or more pounds in one day or five pounds in one week. Weight records showed the resident gained 4.0 lbs from one day to the next on one occasion and 3.4 lbs from one day to the next on another occasion. There was no documentation in the medical record that the physician was notified of these weight gains, and the regional clinical nurse confirmed that the physician was not notified on those dates, contrary to the physician’s order and facility policy requiring notification of changes affecting the resident.
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