Failure to Notify Physician and Representative of Resident’s Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician and the resident’s responsible party of a significant change in a resident’s medical condition, as required by facility policy. The written policy stated that nursing supervisors must notify the attending physician and the resident’s representative of significant changes in the resident’s medical, physical, emotional, or mental condition, any need to alter treatment, and must document these changes in the medical record. For one resident with multiple serious diagnoses, including hypertension, non-traumatic intracerebral hemorrhage, hemiplegia/hemiparesis, tracheostomy, gastrostomy, respiratory failure, diabetes mellitus, and aphasia, the physician had ordered vital signs to be monitored every shift and prescribed several cardiac-related medications, including antihypertensives and anticoagulants. Clinical record review showed multiple pulse readings for this resident over several days, with values both within and below the normal adult range of 60–100 beats per minute, as identified by staff. On specific dates, the resident’s pulse was documented as low as 50–59 beats per minute at various times. Interviews with the DON, an LPN, and a respiratory therapist confirmed the documented pulse readings and that the physician was not notified of these irregular pulse values on the identified days. The LPN and respiratory therapist each acknowledged awareness of the normal adult pulse range and confirmed that the physician had not been alerted to the changes in the resident’s medical status, constituting noncompliance with the facility’s own change-in-condition notification policy and applicable state regulations.
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