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Based on interview, record review, and review of facility policy it was determined the facility failed to ensure a Registered Nurse (RN) supervised and evaluated the nursing care for one of ten sampled patients (Patient #1). Patient #1 was admitted to the facility on 06/16/12, with diagnoses that included Shortness of Air, Hypertension, and Possible Congestive Failure. Record review for Patient #1 revealed on 06/20/12, the patient experienced a change in condition. Based on documentation in the record, on 06/20/12, Patient #1 experienced confusion, was "very short of breath," and the patient's blood pressure was not within normal limits. However, facility staff failed to notify the physician of the change in the patient's condition for approximately seven hours after the initial change in the patient's condition occurred. Patient #1 requested to be transferred to another acute care facility for further care and treatment and was transferred on 06/20/12.

The findings include:

A review of the facility policy titled Notification of Physician of Change in Patient Condition, dated 02/06/08, revealed it was the responsibility of the nurse performing the assessment to appropriately communicate new clinical information to the responsible physician. Further review of the facility policy revealed changes in condition that should be communicated to the patient's physician included changes in mental status and changes in vital signs that indicate possible deterioration of patient status.

A review of the medical record for Patient #1 revealed the facility admitted the patient on 06/16/12, with diagnoses that included Shortness of Air, Hypertension, and Possible Congestive Failure. Further review of the medical record revealed on 06/20/12, Registered Nurse (RN) #1 documented Patient #1 awoke from sleep at 2:00 AM, was "very confused," and was attempting to get out of bed. Continued review of RN #1's documentation revealed Patient #1 was also assessed to be "very short of breath," the "wheezing" (abnormal lung sounds) in the patient's lungs had gotten worse, and the patient's blood pressure was 200/93 (normal range 120/80). RN #1 documented the patient's status had been reassessed and had returned to baseline after 30 minutes. Continued review of the medical revealed Patient #1 experienced another change in condition at 5:00 AM. The patient's medical record revealed RN #1 assessed Patient #1 at 5:00 AM, and noted the patient was "very disoriented and confused," the patient's wheezing had become considerably worse, the patient's lungs sounded "wet as well as wheezy," and the patient's blood pressure was 193/94 (normal limit 120/80). Documentation in the medical record revealed RN #1 "passed" the information related to Patient #1's condition to the oncoming nurse at the change of shift and noted that Patient #1 "may need further order for nebulizer treatments, perhaps Lasix [diuretic] due to symptoms of high blood pressure and wet lungs." Record review revealed no evidence RN #1, or any other staff person, had notified Patient #1's physician of the change in the patient's condition, and on 06/20/12, at 9:08 AM (approximately seven hours after the patient experienced the initial decline in his/her condition), the physician assessed the patient, noted the patient's condition had declined, and at the patient's request, the patient was transferred to another acute care facility for specialized treatment.

Interview with RN #1 on 08/09/12, at 9:35 AM, confirmed she had not contacted Patient #1's physician when the patient experienced a change in condition on 06/20/12. Further interview with RN #1 revealed the RN should have contacted the patient's physician, instead of passing it to the oncoming nurse in shift report.

Interview with RN #2 on 08/09/12, at 9:45 AM, revealed nursing staff had been trained to contact a patient's physician when a change in the patient's condition occurred. According to RN #2, he received shift report from RN #1 on 06/20/12, but could not recall providing care to Patient #1 on 06/20/12.

Interview on 08/09/12, at 12:30 PM, with RN #3, the Clinical Coordinator, revealed facility staff was to contact the patient's physician when a patient experienced a change in condition. Further interview revealed RN #1 should have contacted Patient #1's physician when the patient experienced changes in mental status and vital signs and when the patient's lung sounds became worse.

An attempt to interview Patient #1's physician was made on 08/09/12, at 1:30 PM, but the physician could not be contacted.

An interview on 08/09/12, at 1:50 PM, with the Medical Director for the physician's group that provided care for Patient #1 confirmed staff should notify the physician when a patient experiences a change in condition, including changes in mental status, vital signs and worsening in lung sounds, at the time the changes occurred.