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Based on record review, interview, and policy review, the facility failed to ensure the physician was notified of a change in condition. This affected one (Patient #4) of ten patients reviewed.

See A395.

Based on record review, interview, and policy review, the facility failed to ensure the physician was notified of a change in condition. This affected one (Patient #4) of ten patients reviewed.

Findings include:

Record review revealed Patient #4 was transferred from an outside hospital on 08/21/24 at 4:10 PM with a diagnosis of respiratory failure. The patient's code status was a full code. An attending physician's history and physical noted the patient had a past medical history of Parkinson's disease. The patient had an out-of-hospital pulseless electrical activity arrest. Return of spontaneous circulation was achieved with 15 minutes of resuscitative efforts. An MRI was suggestive of anoxic brain injury, however, the patient's family requested the hospital insert a tracheostomy and percutaneous endoscopic gastrostomy (PEG) tube on 08/15/24. The patient was transferred to the facility for long-term acute care including ventilator management. Telemetry was ordered every four hours.

The patient's vital signs on admission included a blood pressure of 144/77 millimeters of mercury (mm/hg), heart rate of 91 beats per minute, respiratory rate of 30, and temperature of 97.4 degrees Fahrenheit (F). By 08/22/24 at 9:10 AM, the patient's blood pressure was low at 94/55 mm/Hg. At 9:31 PM, the patient's temperature was elevated 101.4 degrees F. There was no documentation the physician was notified of Patient #4's elevated temperature or low blood pressure.

On 08/23/24 at 12:33 AM, Patient #4's temperature remained elevated at 101.4 degrees F. At 12:47 PM, the patient's temperature was 100.5 degrees F and his blood pressure was 84/56 mm/hg. A nursing note revealed the physician was notified and the patient's responsible party was notified, as he was at the bedside of the patient. The sepsis protocol was initiated. At 8:51 PM, Patient #4's temperature was 101.6 degrees F, his blood pressure was 88/53 mm/hg, and respirations were 36 breaths per minute. There was no documentation the physician was notified of Patient #4's elevated temperature or low blood pressure.

On 08/24/24 at 8:38 AM, an order changed the patient's code status to a Do Not Resuscitate (DNR) Comfort Care-Arrest. At 12:37 PM, the patient's blood pressure was 89/57 mm/Hg. By 5:03 PM, Patient #4's temperature was 101.6 degrees F and his blood pressure was 82/48 mm/hg. The patient's blood pressure remained low. The patient experienced cardiac arrest and according to the expiration summary was pronounced deceased at 10:03 PM.

During an interview on 10/31/24 at 2:30 PM, Staff A and Staff B confirmed that the medical record lacked documentation the physician was notified when Patient #4 experienced an elevated temperature and low blood pressure.

The facility policy titled "Interdisciplinary Assessment and Re-Assessment", effective June 2023 stated an acute change of condition is a clinically important change from a patient's established and documented baseline in physical, cognitive, behavioral, or functional domains. An acute change in condition may occur abruptly or over several hours or several days, presenting as physical changes or as changes in function, mood, cognition, or behavior. In the long-term acute care hospital setting a primary goal of identifying acute changes of conditions is to enable staff to evaluate and manage a patient and avoid transfer to a hospital emergency room. To achieve this goal, nurses as well as physicians must recognize a change in condition. Changes in the condition of the patient are determined by assessments using clinical parameters, current and past documented medical condition, medical orders, and/or by patient safety factors. The nurse assigned to the patient is responsible for notification of and communication to the patient's primary physician. The nurse is instructed to notify the nursing supervisor of patient change in condition. The patient's family/significant other should also be notified. Any change in condition, notification, and interventions should be documented in the medical record.