Failure to Notify Family and Physician of Change in Condition
Penalty
Summary
The facility failed to notify the family and/or physician of a change in condition in a timely manner for two residents. Resident R17, who was admitted with diagnoses including Chronic Obstructive Pulmonary Disease and respiratory failure, experienced a significant change in condition on 10/30/24, showing signs of respiratory distress and was transferred to the hospital. However, the facility did not inform the resident's sister until 11/1/24, after the resident had already been moved to the Intensive Care Unit. The sister expressed her upset at not being notified earlier. Resident R39, admitted with overactive bladder and kidney disease, showed signs of lethargy, weakness, and red-colored urine on 12/1/24. Although the nurse practitioner was notified and advised to monitor the resident's vitals, the facility failed to notify the resident's provider as ordered. The resident's daughter was informed of the condition change and requested hospital evaluation due to the rapid decline, but the lack of timely notification to the provider was confirmed by the Assistant Director of Nursing.
Plan Of Correction
MD was retroactively notified regarding change of condition for R39 and R17. R17 family was informed/notified. Whole house audit completed to ensure no additional residents were affected. Nursing staff will be educated on MD and family notification for change in condition and proper documentation on or before 2/11/2025. Resident events/change in condition will be audited daily times 4 weeks and monthly times one month to ensure proper MD and family notification of events and changes in conditions. Audit results will be reviewed through the monthly QAPI process/meeting.