Failure to Provide Timely Emergency Care for Resident with Behavioral Changes
Summary
The facility failed to provide timely emergency services for a resident, identified as Resident #8, who exhibited a significant change in behavior following an electroconvulsive therapy (ECT) treatment. The resident, who had diagnoses of bipolar disorder, anxiety, and depression, and was noted to have intact cognition, began displaying erratic behaviors such as urinating on the floor and undressing in public areas. Despite these changes, there was no documentation of an assessment or physician notification during the night when the behaviors were first observed. Staff interviews revealed that the resident's behavior was notably different from his usual demeanor, which was typically calm and sociable. Staff members reported that the resident appeared disoriented and behaved inappropriately, yet the facility did not notify a physician or send the resident for evaluation until the following morning. The Director of Nursing acknowledged that a change in mental status should prompt immediate provider notification, which did not occur in this instance.
Penalty
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A resident with moderate cognitive impairment fell in the facility's common area and later reported hip pain. Despite the resident's complaints, the on-call service instructed staff to wait until morning to contact the physician. An X-ray the next day revealed a hip fracture, leading to the resident's transfer to the emergency department. The delay in physician notification and response was identified as a deficiency.
A facility failed to ensure 24-hour physician response, affecting a resident with a knee laceration. Despite attempts to contact the on-call nurse practitioner, no return call was received, leading to the resident being sent to the ER without a physician's order. The resident was later diagnosed with acute metabolic encephalopathy and other conditions. Interviews revealed ongoing issues with after-hours physician responsiveness and inadequate communication protocols.
Delayed Physician Notification After Resident Fall
Penalty
Summary
The facility failed to ensure timely physician notification and response to a resident's complaints of pain following a fall. Resident #116, who had diagnoses including chronic obstructive pulmonary disease, major depressive disorder, and essential tremors, fell in the Centrum area on 11/11/24 at 7:50 P.M. The resident was observed by a CNA attempting to walk from her wheelchair and subsequently fell on her right side. Initial assessments by the nursing staff did not reveal any immediate injuries or complaints of pain, and the resident was returned to her wheelchair and later to bed. During the night, the resident began to report pain in the right hip/thigh area. Despite this, the on-call service instructed the staff to contact the physician in the morning rather than immediately. It was not until the morning of 11/12/24 that the physician was contacted, and an X-ray was ordered, revealing an acute subcapital hip fracture. The resident was then sent to the emergency department for further evaluation and treatment. Interviews with the Director of Nursing, the resident's daughter, and nursing staff revealed concerns about the delay in addressing the resident's pain and the lack of immediate physician intervention. The facility staff believed they had followed protocol by contacting the on-call service, but the service's refusal to connect them with the physician resulted in a delay in care. The deficiency was investigated under Complaint Number OH00160374.
Failure to Ensure 24-Hour Physician Response
Penalty
Summary
The facility failed to ensure that physician services responded to requests for resident care 24 hours a day, affecting one resident and potentially impacting all 83 residents. Resident #78, who had a complex medical history including Alzheimer's disease, chronic atrial fibrillation, and other conditions, experienced a laceration on her left knee. Despite attempts to contact the on-call nurse practitioner, there was no return call, and the resident was eventually sent to the emergency room without a physician's order. The incident began when staff noticed bleeding from the resident's left leg and informed the nurse, who assessed the wound and attempted to contact the on-call nurse practitioner. The nurse applied steri strips and a dressing without an order due to the lack of response. The resident's condition worsened, leading to her being sent to the hospital, where she was diagnosed with acute metabolic encephalopathy, acute kidney disease, and mild hypernatremia. Interviews with facility staff revealed ongoing issues with the responsiveness of physician services after hours, which had been previously addressed in their Quality Assurance and Performance Improvement program. The facility's communication protocol did not provide direct contact numbers for the physician or medical director, complicating efforts to obtain timely medical intervention. The resident's representative expressed concern over the delay in communication and the extent of the injury when finally informed.
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