Every resident in a nursing home has an attending physician. The attending physician is the doctor who manages the care of the resident with the assistance of the nursing staff and therapists who care for the resident. He or she is in charge of ordering medication, therapy, and other treatments for the resident and for ordering for non-emergency transfers to the hospital and consultations with other medical specialists.
However, the attending doctor cannot be present in the nursing home 24 hours a day, seven days a week. Most often, the see each resident every 30 days, more often if necessary. In the meantime, they rely on the nursing staff to serve as their “eyes and ears” to keep track of the condition of the resident and to alert them to any significant changes in the resident’s condition.
Nurses will always concede that it is part of their job to alert the doctor of any significant changes in the resident’s condition. This includes things such as:
• Abnormal lab results or other diagnostic testing;
• The occurrence of a fall or accidental injury;
• Changes in mental status;
• The occurrence of a pressure ulcer;
• The worsening of a pressure ulcer such as declining from a Stage 3 pressure ulcer to a Stage 4 pressure ulcer;
• The development of signs and symptoms of infection;
• Complaints of new, significant unexplained pain or other symptoms; or
• Any other problem or complication that cannot be resolved without the assistance of a physician or the entry of orders for new treatments.
When a nurse alerts the doctor of any of the things listed above, the substance of the discussion should be noted in the resident’s chart. If the nurse was unable to reach the doctor, that should also be noted in the resident’s chart. When there are events that occur which require doctor notification and there is no corresponding notation in the chart, this gives rise to a reasonable inference that the nurse did not attempt to notify the doctor as required.
When we review cases where there has been a decline in the resident’s condition over time, one thing that we review the chart closely for is to see whether the nurse recognized the change in condition, whether there was prompt notification of the doctor, and what was communicated to the doctor. These often are key areas where we can show that a bad outcome could have been prevented.