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Based on facility policy and procedure, medical record (MR) review and staff interviews, it was determined the nursing staff failed to notify the physician for an adverse change in a patient's condition. This did affect 1 of 6 Senior Behavior Care Unit (SBCU) MR's review, including Patient Identifier (PI) # 1, and had the potential to negatively affect all patient's served by the SBCU.

Findings Include:

Policy Number: 9171
Subject: Physician Notification of Change in Patient Condition
Revised: 10/17/11

Policy: The physician will be notified immediately of any adverse changes in the patient's condition.

Procedure: The physician and/or consulting physician/surgeon will be notified immediately of any significant change in the patient's condition...

Responsibility: It is the responsibility of the nurse assigned to the patient to determine that the patient's condition has changed significantly and to notify the patient's attending physician, surgeon or consultant.

1. PI # 1 was admitted to the SBCU on 12/6/19 with diagnoses including Neurocognitive Disorder, Vascular, with Behavioral Disturbances and Psychosis Secondary to General Medical Condition.

Review of the Physician Orders dated 12/7/19 at 1:02 AM revealed the following two blood pressure medications were ordered for the patient: Benicar 20 mg (milligrams) prn (as needed) daily and Hydrochlorothiazide (HCTZ) 12.5 mg prn daily.

Review of the Medication Record from 12/7/19 to 12/10/19 revealed the Benicar and HCTZ was administered once during the patient's hospitalization. Benicar 20 mg was administered on 12/9/19 at 18:19 and HCTZ was administered on 12/9/19 at 6:20 PM with documentation of the reason as "for elevated BP".

Review of the Nursing Progress Notes dated 12/7/19 through 12/8/19 revealed documentation the patient's lungs were clear and speech pattern was "WNL (within normal limits)."

Review of the Progress Note by the Medical Certified Registered Nurse Practitioner (CRNP) dated 12/9/19 at 6:50 AM revealed documentation of "patient currently awake in hallway, not very verbal and converse very easily. Patient does not show any current distress at this time..." with a blood pressure of 132/82 and lungs "CTA (Clear to auscultation) Bilaterally."

Review of the Physician Progress note by the Psychiatric CRNP dated 12/9/19 at 8:00 AM revealed documentation of speech as "spontaneous and clear" and a blood pressure (BP) of 132/82.

Review of the Nursing Assessment dated 12/9/19 at 10:09 AM revealed documentation the patient's breath sounds were "clear" and the speech pattern was "mechanical."

Review of the Nursing Assessment dated 12/9/19 at 6:06 PM revealed documentation of "...Speech very slurred, hard to understand..." There was no documentation of the patient's breath sounds.

Review of the Nursing Assessment dated 12/9/19 at 6:26 PM revealed documentation of "pt (patient) blood pressure 168/107 PRN HCTZ and Benicar given..."

Further review of the Nursing Assessment(s) dated 12/9/19 at 10:09 AM, 6:06 PM, and 6:26 PM revealed no documentation the physician was notified of the patient's change in speech pattern and increased blood pressure.

Review of the Nursing Assessment dated 12/10/19 at 1:32 AM revealed documentation of "...non-production (non-productive), congested cough..."

Review of the Nursing Assessment dated 12/10/19 at 1:33 AM revealed documentation of the patient's breath sounds as "diminished" and speech patter as "garbled".

Further review of the Nursing Assessment(s) dated 12/9/19 at 1:32 AM and 1:33 AM revealed no documentation the physician was notified of the patient's change in speech pattern, new non-productive congested cough, and diminished breath sounds.

On 1/16/2020 at 1:14 PM the surveyor asked Employee Identifier # 1, Assistant Director of Nursing, if the facility would expect a nurse to notify a physician immediately for a new onset slurred speech and a blood pressure of 168/107. EI # 1 verbalized "yes" the facility would expect the physician to be notified.