Change of a Resident Condition

Change of a Resident’s Condition

Effective Date: [Original NPP Date]
Revised Date: [Current Date]

Policy

When a resident experiences a significant change in condition, a Registered Nurse (RN) will assess the resident. The physician and responsible party (if applicable) will be notified promptly. Significant changes in condition may include, but are not limited to, cardiac or respiratory arrest, choking episodes, rapid deterioration of condition, significant changes in vital signs, critical lab values, falls, new or severe worsening of existing pain, confusion, agitation, behaviors, pressure sores, and/or wounds.

Procedure

1. Assessment:

   • The resident is assessed by a Registered Nurse immediately upon recognizing a significant change in condition.

2. Notification of Physician:

   • The physician is notified promptly of the change in resident condition. Notification can be verbal or written via fax. Ensure the physician has received and responded to any left messages or transmitted faxes.
   • Document the date, time, physician name, and response in the medical record.

3. Emergency Situations:

   • In all life-threatening situations, call 911 immediately and transfer the resident to the hospital unless the resident has a “Do Not Hospitalize” order.
   • If the physician cannot be reached in a timely manner, the nursing supervisor, using clinical judgment, will determine the need to call the Medical Director and/or transfer the resident to the hospital without a physician order.

4. Notification of Responsible Party:

   • The responsible party of the resident is notified of the change in condition (if applicable). Document the date, time, name of the person spoken to, and the information conveyed.

5. Documentation Guidelines:

   • Documentation should include all observations, assessments, vital signs, and calls made and received regarding the notification of the physician and responsible party.

Documentation Guidelines

1. Observations:

   • Detailed observations of the resident’s condition should be recorded.

2. Assessments:

   • Document the RN’s assessment of the resident’s condition.

3. Vital Signs:

   • Record all pertinent vital signs.

4. Communication:

   • Document all calls made and received, including the date, time, name of the physician or responsible party, and their response.

References:

• Centers for Medicare & Medicaid Services. State Operations Manual, Appendix PP - Guidance to Surveyors for Long-Term Care Facilities. [Link to current CMS SOM]
• CMS Requirements of Participation for Long-Term Care Facilities. [Link to current guidelines]