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Based on record review and interview, the facility failed to ensure nursing provided physician notification and documented physician notification of abnormal patient assessments and vital signs for Patient ID #1.

Findings included:

Record review of HHSC intake received on 12/28/2023 at 12:30 pm stated "the family voiced concerns that the patient had not improved at all since admission ... the patient was displaying tremors, confusion ...sleeping all the time .... The patient presented unresponsive with BP in the 60s during transit (to ED) ...."

Record review of facility policy titled "Assessment/Reassessment", last reviewed 8/17/2023, stated "Assessment and reassessment occurs in accordance with regulatory and state specific requirements at a minimum, and more frequently as indicated by patient condition as described below ... Reassessments are performed by each discipline according to patient's vital signs, laboratory results, status or condition in accordance with the professional's scope of practice ... When there is a significant change in the patient's condition, a full reassessment is performed. Such as but not limited to: there is a change in level of consciousness, significant changes in vital signs or lab results, functional level declines significantly, to determine response to a certain treatment, patient/family requests reassessments or as ordered by a physician."

Review of electronic medical record for patient (ID#1) on 02/06/2024 at 2:25 pm with CNO Staff ID # 52 showed the following information:
Patient ID # 1 was admitted to the facility on 11/20/2023 and discharged 11/30/2023. Patient ID #1 had the following entries with no evidence of provider notification:
Staff ID #71 on 11/21/23 2:44 pm BP 105/56 (Refer Range 90-140/60-90)
Staff ID #73 on 11/21/23 8:39 am BP 95/52 (Refer Range 90-140/60-90)
Staff ID #74 on 11/23/23 6:19 am Temp 100.7F (Refer Range 96.4-99.1)
Staff ID #75 on 11/23/23 11:28 pmBP 112/50 (Refer Range 90-140/60-90)
Staff ID #76 on 11/24/23 8:17 am BP 129/45 (Refer Range 90-140/60-90)
Staff ID #76 on 11/24/23 9:32 am BP 103/45 (Refer Range 90-140/60-90)
Staff ID #77 on 11/25/23 7:37 am BP 97/51 (Refer Range 90-140/60-90)
Staff ID #78 on 11/25/23 06:59 am Sp02 92 (Refer Range 94-100)
Staff ID #81 on 11/29/23 09:22 am Sp02 82 (Refer Range 94-100)
Staff ID # 80 on 11/29/23 8:57 pm Sp02 92 (Refer Range 94-100)

Record review of Therapy Services Records provided by Director Therapy Services Staff ID # 54 on 2/6/24 at 3:15 pm stated that on 11/30/23 Patient ID#1 had "no functional engagement at this point in session ... 30 minutes missed due to lack of engagement."

Interview with Chief Nursing Officer Staff ID #52 on 2/06/2024 at 2:25 pm, confirmed that patient's vital signs outside established "normal or ordered" parameters and clinical status changes such as "confusion and altered mental status" should prompt notification to the patient's physician and documentation of this notification in the medical record. She confirmed she would expect to see this recorded in medical record. She confirmed she would expect to see patient more frequently than the Q 12 hours or per shift assessment for clinical status changes. She also confirmed that she would expect that a patient who was an "acute care transfer" to have vital signs and a recent assessment performed and documented within 1 hour of their departure from facility. She confirmed there was no evidence of vital signs or re-assessment performed within an hour of acute care transfer for Patient ID #1.

Interview with Director of Therapy Services Staff ID #54 on 2/6/24 at 3:15 pm. He confirmed that the therapy services staff should notify nursing of any clinical issues, barrier to therapy, vital sign issues or patient changes which occur during therapy sessions.