F0580

G

Failure to Notify Physician and Family of Resident’s Change in Condition Prior to Discharge

Rapid City, South Dakota Survey Completed on 03-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to promptly notify a physician and the resident’s first emergency contact of a significant change in condition for one resident. On the morning in question, the resident experienced three to four episodes of bile-colored emesis between 6:00 a.m. and 7:00 a.m., appeared more tired, and had oxygen saturation readings of 88–89% on room air. A CNA reported the vomiting and dry heaving to the RN, who assessed the resident, obtained vital signs, held morning medications due to vomiting, and left the resident in bed with the head elevated, a vomit bag, call light, and a garbage can nearby. Later, around 8:30 a.m., the RN and CNA provided incontinence care after a bowel episode and observed that the resident appeared weak, pale, and unable to remain upright, after which the resident requested to return to bed. Despite these findings, the RN did not contact the physician or the resident’s first emergency contact at that time.

The resident had been admitted for rehabilitation following a fall at an assisted living facility that resulted in a left femur fracture and was taking aspirin twice daily as a blood thinner. Prior lab work showed mildly low hemoglobin and hematocrit. It had been determined by the facility’s PA-C and the DON at the resident’s assisted living facility that the resident was doing well and was appropriate for readmission to assisted living later that morning. However, when the resident’s granddaughter arrived around 10:30 a.m. to complete discharge paperwork, she observed that the resident did not look well and questioned whether she should be evaluated before discharge. The RN then reassessed the resident, documented a blood pressure of 89/57, and noted increased lethargy after the resident was seated in a wheelchair. There is no documentation that the physician or first emergency contact was notified at this point, despite the documented change in condition.

Following this reassessment, the granddaughter contacted the assisted living facility’s executive director, who advised that the resident be taken to urgent care or the ER before readmission. Around 11:00 a.m., the CNA assisted the granddaughter in transferring the resident into the granddaughter’s vehicle and observed that the resident’s condition worsened and she became unresponsive in the car. The granddaughter stated she was taking the resident to the ER, where the resident was evaluated and admitted to the hospital. Subsequent CT imaging revealed an acute and chronic subdural hematoma, a 12 mm meningioma, a pulmonary embolism, and cholecystitis. Record review confirmed there was no documentation that the resident’s physician or first emergency contact had been notified of the change in condition while the resident was still at the facility. Interviews with the RN, administrator, DON, and the physician confirmed that the RN did not notify the physician or the first emergency contact, despite facility policies and the RN job description requiring prompt notification of significant changes in condition and consultation with the medical provider and resident representative.

Facility policies reviewed included a Notification of Change of Condition policy requiring prompt informing of the resident, consultation with the medical provider, and notification of the resident representative when there is a significant change in physical, mental, or psychosocial status, and a Discharge and Transfer policy requiring that if a resident’s needs change during discharge planning, the discharge plan may be updated and discharge should not proceed if the discharge location does not meet the resident’s needs, with contact to the medical provider in such cases. The RN acknowledged in interview that she did not call the physician or the first emergency contact when the resident’s condition changed and stated she had intended to update the family upon arrival and did not think to call the physician. The administrator and DON acknowledged that the physician and first emergency contact were not contacted when the resident’s condition changed and that the RN should have notified them promptly before discharge.