Ask Proactive – Are there specific requirements for notifying the MD of incidents?

Are there specific requirements for notifying the MD of incidents?

A:

Yes, specific regulatory requirements apply to notifying the physician, as incidents may fall under various categories. These guidelines ensure that physicians are informed in a timely and appropriate manner, depending on the nature of the incident.

1. Incidents Involving Accidents

Requirements for notifying a physician of an accident can be found under Resident Rights, §483.10(g)(14), F580 – Notification of Changes. Appendix PP of the State Operations Manual specifies:

• • (i) A facility must immediately inform the resident, consult with the resident’s physician, and notify the resident representative(s) when there is:
    • • (A) An accident involving the resident that results in injury and has the potential to require physician intervention.
  • (ii) When notifying the physician under this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request.

Notification is based not on the type of accident but on whether an injury “has the potential for requiring physician intervention.” Intervention may include orders for treatment, testing within the facility, transfer to the emergency room, referral for a consult, or other follow-up care. Licensed nurses must complete a thorough assessment of the resident and report all findings, as outlined in part (ii) of this requirement.

2. Incidents Involving Allegations of Abuse (Including Resident-to-Resident Altercations)

Requirements for notifying the physician in cases of abuse allegations are also detailed in F580 – Notification of Changes, specifically sections (B), (C), and (D):

• • (i) A facility must immediately inform the resident, consult with the resident’s physician, and notify the resident representative(s) when there is:
    • • (B) A significant change in the resident’s physical, mental, or psychosocial status.
      • (C) A need to alter treatment significantly, such as discontinuing an existing treatment due to adverse effects or beginning a new treatment.
      • (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii).

Abuse allegations may result in a significant change in physical status (e.g., injury) or mental/psychosocial status due to the incident’s impact. Such situations must be reported to the physician. Additionally, unknown-origin injuries requiring new or altered treatment and any transfer or discharge decisions must be promptly communicated to the physician.

3. Incidents Involving New Pressure Ulcers

Notification requirements for newly identified pressure ulcers are specified under both F580 and F686 – Pressure Ulcers:

• • §483.25(b)(1) Pressure Ulcers: Based on a resident’s comprehensive assessment, the facility must ensure:
    • • (i) The resident receives preventive care to avoid pressure ulcers unless clinically unavoidable.
      • (ii) The resident receives necessary treatment and services to promote healing, prevent infection, and avoid new ulcers.

To promote effective pressure ulcer management, the facility must assess and communicate findings to the physician for necessary orders. Additionally, sections (B), (C), and (D) of F580 apply here, covering significant changes, treatment commencement or alteration, and possible transfer or discharge.

Since the physician is primarily responsible for resident care orders, it is crucial for facility staff to follow all notification requirements and adhere to policies for timely follow-up when the physician cannot be reached immediately. Documentation is essential to verify that notification is complete. This includes detailed records of the notification, the information provided, and the physician’s response.

Written by:

Janine Lehman, RN, RAC-CT, CLNC

Director of Legal Nurse Consulting

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