Failure to Notify Physicians and Families of Significant Changes in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify physicians and family representatives of residents’ changes in condition as required by policy. For one resident with diagnoses including pelvic fracture, chronic pain, PTSD, depression, epilepsy, and hypertension, the care plan directed staff to monitor vital signs and notify the medical doctor of significant abnormalities. Physician orders included clonidine 0.1 mg by mouth every 8 hours as needed for systolic blood pressure greater than 170. Vital sign records showed multiple elevated systolic blood pressures, including 171, 174, 206, and 219 over several months. Progress notes from early December through mid-March contained no documentation that the physician was notified of the elevated blood pressures on specific dates when readings were 206 and 219. The resident reported concern that his blood pressure was often too high and stated that his cardiologist had informed him that no one from the facility was reporting abnormal blood pressure readings. The DON confirmed there was no documentation of notification to the primary physician or cardiologist regarding these high blood pressures. The deficiency also includes failure to notify the physician of a significant weight loss for another resident with diagnoses including diabetes mellitus, Down’s Syndrome, Hirschsprung’s disease, and morbid obesity, who had severe cognitive impairment and was dependent on staff for activities of daily living. A weight loss note documented that this resident’s weight decreased from 241 pounds to 183.7 pounds over several months, constituting a significant weight loss. The medical record did not contain documentation that the physician was notified of this significant weight loss. The ADON confirmed the absence of documentation supporting physician notification. Facility policy on impaired nutrition and unplanned weight loss required staff to report any significant weight gains or losses or abrupt or persistent changes from baseline appetite or food intake to the physician. This deficiency was investigated under a specific complaint number.
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